Piel Seca:_____________________Piel Hidratada:___________________________________________ FICH A DE DIAGNOSTICO

Piel Seca Atípica:________________Piel Seca Senil:_______________________________________ I DATOS PERSONALES

Piel Grasa:_______________________Piel Grasa Asticciada:________________________________ Nombres y

Apellidos:__________________________________________________________________________
Piel Grasa Sensible:_____________________________________________________________________
Fecha de Nacimiento:_____________________________________________________________
Piel Grasa Seborreica Afluente:________________________________________________________
Estado Civil:_______________________________________________________________________
Piel Mixta y Acne:________________________________________________________________________
Direcció n:__________________________________________________________________________
VII. DIAGNOSTICO:
Teléfono:___________________________________________________________________________
_____________________________________________________________________________________________
Correo Electró nico:_______________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Tratamiento:______________________________________________________________________

Profesió n:__________________________________________________________________________
VII. TRATAMIENTO: UNEPEELING QUIMICO

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

FECHA PRODUCTO TIEMPO DE EFECTO

QUIMICO TOLERANCIA
II. DATOS PATOLOGICOS V. CARACTERISTICAS

DIABETES:______________________________________________________________________________ Textura Gruesa:___________________________________________________________________________

CANCER:________________________________________________________________________________ Textura Delgada:__________________________________________________________________________

ASMA:___________________________________________________________________________________ Textura Aspera:___________________________________________________________________________

PROBLEMAS HORMONALES:_________________________________________________________ Textura Lisa y Fina:_______________________________________________________________________

CIRUGIA RECIENTE:___________________________________________________________________ Textura Granulosa:_______________________________________________________________________

Antibioticos:____________________Alcohol:__________________Tabaco:___________________ Textura Opaca:____________________________________________________________________________

III. CIRUGIAS ESTETICAS Poros cerrados:_______________________Dilatados:_________________________________________

Rinoplastia:____________________________________________________________________________ Poco Visible: ______________________________________________________________________________

Abdominoplastia:_____________________________________________________________________ Color Rosada:_________________________Palida:_____________________________________________

Implantes Faciales:___________________________________________________________________ Gris:_____________________________Amarillenta:____________________________________________

Blefaroplastia:________________________________________________________________________ Amarilla:_________________________Enrojecida:____________________________________________

Liftin Facial:__________________________________________________________________________ Untuosa:___________________Oleosa:__________________Brillosa:____________________________

IV. ALTERACIONES CUTANEAS Comedones Negros o Blancos:__________________________________________________________

Nevus:______________________________Cloasma:________________________________________ Arrugas y Líneas de Expresió n:_________________________________________________________

Petequias:____________________________Papula:________________________________________ Entrecejos Periorbiculares:_____________________________________________________________

Vasicula:________________________Comedones:________________________________________ Naso Geniano:____________________________________________________________________________

Lentigus:____________________________Cicatriz:________________________________________ Peribucales:_______________________________________________________________________________

Telegentasia:________________________________________________________________________ VI BIOTIPO CUTANEO:

Costra:________________________________________________________________________________ EUDERMICA O NORMAL:_______________________________________________________________

Melasma:_____________________________________________________________________________ _____________________________________________________________________________________________

Milliun:_______________________________________________________________________________ _________________________ ______________________

Acne:_________________________________________________________________________________ Firma del Paciente Cosmeatra