Piel Seca:_____________________Piel

Hidratada:___________________________________________
Piel Seca Atpica:________________Piel Seca
Senil:_______________________________________
Piel Grasa:_______________________Piel Grasa
Asticciada:________________________________
Piel Grasa
Sensible:____________________________________________________________
_________
Piel Grasa Seborreica
Afluente:________________________________________________________
Piel Mixta y
Acne:________________________________________________________________
________
VII. DIAGNOSTICO:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___
PRODUCTO
QUIMICO

TIEMPO DE
TOLERANCIA

I DATOS PERSONALES
Nombres y
Apellidos:___________________________________________________________
_______________
Fecha de
Nacimiento:_________________________________________________________
____
Estado
Civil:________________________________________________________________
_______

VII. TRATAMIENTO: UNEPEELING QUIMICO

FECHA

FICH A DE DIAGNOSTICO

EFECTO

Direccin:___________________________________________________________
_______________
Telfono:____________________________________________________________
_______________
Correo
Electrnico:_________________________________________________________
______
Tratamiento:________________________________________________________
______________

Profesin:___________________________________________________________
_______________

II. DATOS

CIRUGIA
RECIENTE:___________________________________________________________
________
V. CARACTERISTICAS
Textura
Gruesa:_____________________________________________________________
______________

PATOLOGICOS
DIABETES:___________________________________________________________
___________________
CANCER:____________________________________________________________
____________________
ASMA:_______________________________________________________________
____________________
PROBLEMAS
HORMONALES:______________________________________________________
___
Antibioticos:____________________Alcohol:__________________Tabaco:___
________________
III. CIRUGIAS ESTETICAS

Textura
Delgada:____________________________________________________________
______________
Textura
Aspera:_____________________________________________________________
______________
Textura Lisa y
Fina:________________________________________________________________
_______
Textura
Granulosa:__________________________________________________________
_____________
Rinoplastia:_________________________________________________________
___________________

Abdominoplastia:____________________________________________________
_________________
Implantes
Faciales:_____________________________________________________________
______
Blefaroplastia:_______________________________________________________
_________________
Liftin
Facial:_______________________________________________________________
___________

Textura
Opaca:______________________________________________________________
______________
Poros
cerrados:_______________________Dilatados:___________________________
______________
Poco Visible:
_____________________________________________________________________
_________

IV. ALTERACIONES CUTANEAS

Color
Rosada:_________________________Palida:______________________________
_______________

Nevus:______________________________Cloasma:_______________________
_________________

Gris:_____________________________Amarillenta:_______________________
_____________________

Petequias:____________________________Papula:_______________________
_________________

Amarilla:_________________________Enrojecida:________________________
____________________

Vasicula:________________________Comedones:________________________
________________

Untuosa:___________________Oleosa:__________________Brillosa:________
____________________

Lentigus:____________________________Cicatriz:________________________
________________

Comedones Negros o
Blancos:__________________________________________________________

Telegentasia:________________________________________________________
________________

Arrugas y Lneas de
Expresin:_________________________________________________________

Costra:______________________________________________________________
__________________

Entrecejos
Periorbiculares:______________________________________________________
_______

Melasma:___________________________________________________________
__________________
Milliun:______________________________________________________________
_________________
Acne:________________________________________________________________
_________________

Naso
Geniano:____________________________________________________________
________________
Peribucales:_________________________________________________________
______________________
VI BIOTIPO CUTANEO:

EUDERMICA O
NORMAL:___________________________________________________________
____
_____________________________________________________________________
________________________

_________________________
______________________
Firma del Paciente
Cosmeatra