Piel Seca:_____________________Piel Hidratada:___________________________________________

Piel Seca Atípica:________________Piel Seca Senil:_______________________________________

Piel Grasa:_______________________Piel Grasa Asticciada:________________________________

Piel Grasa Sensible:_____________________________________________________________________

Piel Grasa Seborreica Afluente:________________________________________________________

Piel Mixta y Acne:________________________________________________________________________

VII. DIAGNOSTICO:

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VII. TRATAMIENTO: UNEPEELING QUIMICO

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FECHA PRODUCTO QUIMICO

TIEMPO DE TOLERANCIA

EFECTO

FICH A DE DIAGNOSTICO

I DATOS PERSONALES

Nombres y Apellidos:__________________________________________________________________________

Fecha de Nacimiento:_____________________________________________________________

Estado Civil:_______________________________________________________________________

Dirección:__________________________________________________________________________

Teléfono:___________________________________________________________________________

Correo Electrónico:_______________________________________________________________

Tratamiento:______________________________________________________________________

Profesión:__________________________________________________________________________

II. DATOS PATOLOGICOS

DIABETES:______________________________________________________________________________

CANCER:________________________________________________________________________________

ASMA:___________________________________________________________________________________

PROBLEMAS HORMONALES:_________________________________________________________

CIRUGIA RECIENTE:___________________________________________________________________

V. CARACTERISTICAS

Textura Gruesa:___________________________________________________________________________

Textura Delgada:__________________________________________________________________________

Textura Aspera:___________________________________________________________________________

Textura Lisa y Fina:_______________________________________________________________________

Textura Granulosa:_______________________________________________________________________

Antibioticos:____________________Alcohol:__________________Tabaco:___________________

III. CIRUGIAS ESTETICAS

Rinoplastia:____________________________________________________________________________

Abdominoplastia:_____________________________________________________________________

Implantes Faciales:___________________________________________________________________

Blefaroplastia:________________________________________________________________________

Liftin Facial:__________________________________________________________________________

IV. ALTERACIONES CUTANEAS

Nevus:______________________________Cloasma:________________________________________

Petequias:____________________________Papula:________________________________________

Vasicula:________________________Comedones:________________________________________

Lentigus:____________________________Cicatriz:________________________________________

Telegentasia:________________________________________________________________________

Costra:________________________________________________________________________________

Melasma:_____________________________________________________________________________

Milliun:_______________________________________________________________________________

Acne:_________________________________________________________________________________

Textura Opaca:____________________________________________________________________________

Poros cerrados:_______________________Dilatados:_________________________________________

Poco Visible: ______________________________________________________________________________

Color Rosada:_________________________Palida:_____________________________________________

Gris:_____________________________Amarillenta:____________________________________________

Amarilla:_________________________Enrojecida:____________________________________________

Untuosa:___________________Oleosa:__________________Brillosa:____________________________

Comedones Negros o Blancos:__________________________________________________________

Arrugas y Líneas de Expresión:_________________________________________________________

Entrecejos Periorbiculares:_____________________________________________________________

Naso Geniano:____________________________________________________________________________

Peribucales:_______________________________________________________________________________

VI BIOTIPO CUTANEO:

EUDERMICA O NORMAL:_______________________________________________________________

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Firma del Paciente Cosmeatra