Professional Documents
Culture Documents
FICHA N _____________
DATA: ____/____/______
DADOS DO CLIENTE
HORA: ___:___
CADASTRO N
Nome:
Endereo: ________________________________________________________________
______________________________ Bairro _____________________________________
N__________ Cidade ________________________________ UF ___________________
Complemento _____________________________________________________________
__________________________________ E-mail _________________________________
Telefone: (___) _________________________ Celular: (___)________________________
Estado Civil:
Casado(a)
Sim
No ________________
Regular
Sim
Sim
Hiperlipdica
Sim
Sim
Sim
Hipercalrica
Sim
Sim
No
No
No Alimentao:
No _____
Regular
Hiperglicmica
Irregular ___
frequncia? _______________________________________________________________
Ingesto diria de gua:
Nenhuma
Muito pouca
Pouca
Sucos
Refrigerantes
Sim
_____________________________
No Possui problemas renais?
Sim
Chs
No sei
No ____
_________________________________________________________________________
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Alta
Possui marca-passo?
Sim
Baixa
Sim
No Obs.: _____________________________________
Sim
Sim
No Obs.: ____________________
Sim
No
Sim
Sim
No
Utiliza algum
Sim
8h/dia
Leve
Menos de 8h/dia
Sim
Sim
Sim
No Qual: ________________________
No Usa lentes de contato?
Sim
No
No Frequncia: ______________________________________
Sim
Sim
tratamento: _______________________________________________________________
________________________________________________________________________
Possui antecedentes oncolgicos?
Sim
No Obs.: __________________________
________________________________________________________________________
Alguma doena no mencionada? _____________________________________________
_________________________________________________________________________
_________________________________________________________________________
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AVALIAO DA PELE
CARACTERSTICAS CUTNEAS
MANCHAS PIGMENTARES RELACIONADAS MELANINA
PRESENA
ACROMIA
CLOASMA
EFLIDES
HIPERCROMIA
HIPOCROMIA
_______________________________________________________
MANCHAS POR ALTERAES VASCULARES
ANGIOMA
CIANOSE
ERITEMA
HEMATOMA
TELEANGECTASIAS
_______________________________________________________
FORMAES SLIDAS
CERATOSE
PPULAS
NDULOS
VERRUGAS
MILLIUM
NECROSE
COMEDO
_______________________________________________________
FORMAES COM CONTEDO LIQUDO
BOLHA
PSTULA
VESCULA
_______________________________________________________
_______________________________________________________
LESES DE PELE
CROSTA
DESCAMAO
ESCARA
FISSURA
FSTULA
ESCORIAO
ULCERAO
_______________________________________________________
SEQUELAS
ATROFIA
CICATRIZ
_______________________________________________________
_______________________________________________________
PELOS
HIPERTRICOSE
ALTERAES DE QUERATINIZAO
ECZEMA
HIRSUTISMO
HIPERQUERATOSE
PSORASE
_______________________________________________________
_______________________________________________________
CLASSIFICAO DO FOTOTIPO CUTNEO
FOTOTIPO I
FOTOTIPO II
FOTOTIPO V
QUANTO HIDRATAO
FOTOTIPO III
FOTOTIPO IV
FOTOTIPO VI
DESIDRATADA
NORMAL
_______________________________________________________
_______________________________________________________
QUANTO AO GRAU DE OLEOSIDADE
ALPICA
LIPDICA
NORMAL
SEBORREICA
_______________________________________________________
_______________________________________________________
QUANTO ESPESSURA
ESPESSA
FINA
MUITO FINA
_______________________________________________________
_______________________________________________________
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PLANO DE TRATAMENTOS
TRATAMENTOS E DETALHAMENTO
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CALENDRIO
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PLANO DE TRATAMENTOS
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PLANO DE TRATAMENTOS
TRATAMENTOS E DETALHAMENTO
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CALENDRIO
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OBSERVAES: ____________________________________________________________
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ASSINATURAS
CIDADE:__________________________________________UF______ DATA: ____/____/______
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CLIENTEN DO RG________________________
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