Kassia Spa

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FIȘĂ TEHNICĂ FACE

DATA:___________________________________________________
1. DATE PERSONALE
Nume și
prenume:________________________________________________________________________________
Data nașterii:_____________________ Vârsta:______ # Copii:_____ EPS:______________________
Adresa:_________________________________________________ E-mail:_________________________
Ocupație:________________________________ Telefoane:____________________________________

2. MOTIVUL CONSULTĂRII
______________________________________________________________________________________________
______________________________________________________________________________________________

3. DATE CLINICE
la. BOLI FAMILIE
Diabet Astm Hipertensiune Cancer Altele
Care__________________________________
b. BOALA PERSONALĂ
Boli pe care le-ați suferit:
________________________________________________________________________________
Boli de care suferiți în prezent: ____________________________________________________________
Medicamentele pe care le
luați:________________________________________________________________________________
Metoda de planificare (femei) _________________________________________________
Utilizare protetică: Lentile de contact dentare Nici unul

4. DATE ESTETICE
la. IMPLANTES SAU GRAFTE
Bărbie Obraji Nas Niciuna
b. CHIRURGIE ESTETICĂ ȘI TRATAMENTE ESTETICĂ
blefaroplastie Rinoplastie bichectomie Nici unul
otoplastie Lifting facial septoplastie
c. PROCEDURI ESTETICE
Aplicație Acid plasmatic Vitamina Niciuna
Botox hialuronic autolog C
Cât timp?_______________________________________________

5. Analiza estetică
la. CULOAREA
PIELII__________________________________________________________________________
b. TIPOLOGIA PIELEI
____________________________________________________________________________
Piele normală Piele mixtă Piele uscată Piele grasă
Piele asfixiată Piele devitalizată Piele hidratată
c. GRAD DE DESHIDRATARE
Ușoară Medie Ridicată
d. GROSIMEA PIELEI
Fin Mediu Fin Mediu Mediu Gros Gros
și. PATOLOGII CUTANATE
Eritem Telangiectazii Papule Melasma Hiperpigmentare
Bístere Couperoza Pustule Riduri Vasculare Stele
Vezicule Cicatrici Chisturi Micoze Berloque Dermatită
Angioame Millium Ephelides Scab hirsutism
Comedoane Negi Nevus Keratoza Urticarie
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Eczemă Noduli Vitiligo
F. TENDINȚA ACNEEI DA NU Tipul de acnee________________________________

g. ALERGIE LA PRODUSE
Machiaj Crema Hidrata Crema Hranitoare Altele Nici unul
Care?____________________________________________________________________________________
Compuși activi specifici: miere căpșuni struguri migdale Altele Nici unul
Care?____________________________________________________________________________________
h. PROCEDURA DE EFECTUAT
_________________________________________________________________________________________
6. OBSERVAȚII GENERALE
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7. ANGAJAMENTUL LEGAL
eu ____________________________________________________________ identificat cu cardul de cetățenie
N°_____________________ Certific că informațiile furnizate aici sunt adevărate; Autorizez cosmeticianul
sa efectueze urmatorul tratament
_________________________________________________________________ Cunosc toate efectele si
contraindicatiile acestuia, accept recomandarile sugerate si exonerez
________________________________________________________ de orice responsabilitate pentru orice
alterare ce poate aparea din cauza tratamentului ce urmeaza a fi efectuat.

SEMNĂTURA UTILIZATOR SEMNĂTURA COSMETICIANĂ

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8. ANEXE

DATA:__________________________

TRATAMENT TREBUIE EFECTUAT

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TRATAMENT EFECTUAT ________________________________________________________________

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OBSERVAȚII________________________________________________________________________________
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SEMNĂTURA UTILIZATOR SEMNĂTURA COSMETICIANĂ

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g. ALERGIE LA PRODUSE
Machiaj Crema Hidrata Crema Hranitoare Altele
Care?____________________________________________________________________________________
Compuși activi specifici: miere căpșuni struguri migdale Altele
Care?____________________________________________________________________________________
h. PROCEDURA DE EFECTUAT
_________________________________________________________________________________________
6. OBSERVAȚII GENERALE
__________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________
7. ANGAJAMENTUL LEGAL
eu ____________________________________________________________ identificat cu cardul de cetățenie
N°_____________________ Certific că informațiile furnizate aici sunt adevărate; Autorizez cosmeticianul
sa efectueze urmatorul tratament
_________________________________________________________________ Cunosc toate efectele si
contraindicatiile acestuia, accept recomandarile sugerate si exonerez
________________________________________________________ de orice responsabilitate pentru orice
alterare ce poate aparea din cauza tratamentului ce urmeaza a fi efectuat.

SEMNĂTURA UTILIZATOR SEMNĂTURA COSMETICIANĂ

CC Nr. CC Nr.