ficha_anamnese_belcol

Prévia do material em texto

Dados Pessoais
Nome CPF
Como chegou a Bel Col?
Histórico
□ Tratamento estético _____________________________________________________________________ □ Com ácidos: _______________________________________________ 
□ Cirurgia estética ____________________________________________________________________ □ Outras cirurgias: __________________________________________ 
□ Antecedentes alérgicos ___________________________________________________________________________________________________________________________________________
□ Alguma doença □ Diabete □ Pressão alta □ Outros: ____________________________________________________________________________ 
□ Patologia dermatológica ___________________________________________________________________________________________________________________________________________
□ Algum medicamento ___________________________________________________________________________________________________________________________________________
□ Método anticoncepcional ___________________________________________________________________________________________________________________________________________
□ Ciclo menstrual regular _______________________________________________________ Data do ultimo ciclo: ______________________________________________________
□ Reposição hormonal ___________________________________________________________________________________________________________________________________________
□ Gestante ___________________________________________________________________________________________________________________________________________
□ Filhos ___________________________________________________________________________________________________________________________________________
□ Dieta ___________________________________________________________________________________________________________________________________________
□ Ingere líquidos ___________________________________________________________________________________________________________________________________________
□ Esportes ________________________________________________________________________________________ Frequência: _________________________________
□ Fumante ___________________________________________________________________________________________________________________________________________
□ Etilista (bebida alcoólica) ___________________________________________________________________________________________________________________________________________
□ Próteses □ Metalica □ Dentária □ Marcapasso □ Outros: ________________________________________________________
□ Problema nasal ou bucal ___________________________________________________________________________________________________________________________________________
□ Intestino regular ___________________________________________________________________________________________________________________________________________
□ Hereditariedade de acne ___________________________________________________________________________________________________________________________________________
□ Exposição ao sol _________________________________________________________________ □ Usa protetor solar: ____________________________________________ 
Queixa principal
________________________________________________________________________________________________________________________________________________________________________
Ficha de Anamnese
Sistema Circulatório
□ Peso nas pernas □ Hematoma com facilidade □ Extremidades frias
□ Varises e/ou varicose □ Sensação de queimor 
Hábito Alimentar 
□ Legumes □ Verdura □ Fibras □ Carne vermelha 
□ Frutas □ Refrigerante □ Doces/chocolates
Alterações vasculares
□ Petéquias □ Cianose □ Eritema □ Telangiectasia □ Hematoma
Manchas
□ Acromia □ Hipocromia □ Hipercromia 
□ Efélides □ Cloasma □ Melasma
Cuidados Diários com a Face:
________________________________________________________________________________________________________________________________________________________________________
Com que sabonete costuma lavar a face? ____________________________________________________________________________________________________________
Usa filtro solar? Quantas vezes ao dia? _______________________________________________________________________________________________________________
Usa algum produto à noite? ___________________________________________________________________________________________________________________________
Formações sólidas
□ Pápula ____________________________________________________________________________________________________________________________________________________
□ Millium ____________________________________________________________________________________________________________________________________________________
□ Comedão aberto ____________________________________________________________________________________________________________________________________________________
□ Comedão fechado ____________________________________________________________________________________________________________________________________________________
□ Verruga ____________________________________________________________________________________________________________________________________________________
□ Nódulo ____________________________________________________________________________________________________________________________________________________
□ Sequela/Cicatriz ____________________________________________________________________________________________________________________________________________________
Características da Pele
Fototipo □ I □ II □ III □ IV □ V □ VI
Flacidez □ Tissular □ Muscular
Acne □ Grau I □ Grau II □ Grau III □ Grau IV
Grau de oleosidade □ Normal □ Oleosa □ Mista □ Seca
Hidratação □ Hidratada □ Semi-hidratada □ Desidratada
Poros □ Dilatados □ Não dilatados
Espessura □ Fina □ Normal □ Espessa
Envelhecimento □ Leve □ Moderado □ Avançado □ Severo
Outros _______________________________________________________________________________________________________________________________________________________
Tratamento proposto/ Princípios Ativos
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
Observações do Profissional
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
Assinatura do cliente Assinatura do Profissional
Data / /