Piel Seca:_____________________Piel Hidratada:___________________________________________

Atypical Dry Skin:________________Senile Dry Skin:_______________________________________ DIAGNOSTIC FILE

Oily Skin:_______________________Oily Asticky Skin:________________________________ I PERSONAL DATA

Piel Grasa Sensible:_____________________________________________________________________ Nombres y

Seborrheic Oily Skin Affluent:________________________________________________________
Combination Skin and
Acne:________________________________________________________________________
Apellidos:__________________________________________________________________________
Fecha de Nacimiento:_____________________________________________________________
Estado Civil:_______________________________________________________________________

VII. DIAGNOSIS: Direcció n:__________________________________________________________________________

_____________________________________________________________________________________________ Teléfono:___________________________________________________________________________
_____________________________________________________________________________________________ Correo Electró nico:_______________________________________________________________
_____________________________________________________________________________________________
Tratamiento:______________________________________________________________________

VII. TREATMENT: CHEMICAL UNEPEELING Profesió n:__________________________________________________________________________

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

DATE CHEMICAL TOLERANCE TIME EFFECT

PRODUCT
II. PATHOLOGIC DATA V. CHARACTERISTICS

DIABETES:______________________________________________________________________________ Textura Gruesa:___________________________________________________________________________

CANCER:________________________________________________________________________________ Textura Delgada:__________________________________________________________________________

ASMA:___________________________________________________________________________________ Textura Aspera:___________________________________________________________________________

PROBLEMAS HORMONALES:_________________________________________________________ Textura Lisa y Fina:_______________________________________________________________________

CIRUGIA RECIENTE:___________________________________________________________________ Textura Granulosa:_______________________________________________________________________

Antibioticos:____________________Alcohol:__________________Tabaco:___________________ Acne:_________________________________________________________________________________

III. AESTHETIC SURGERIES Textura Opaca:____________________________________________________________________________

Rinoplastia:____________________________________________________________________________ Poros cerrados:_______________________Dilatados:_________________________________________

Abdominoplastia:_____________________________________________________________________ Poco Visible: ______________________________________________________________________________

Implantes Faciales:___________________________________________________________________ Color Rosada:_________________________Palida:_____________________________________________

Blefaroplastia:________________________________________________________________________ Gris:_____________________________Amarillenta:____________________________________________

Liftin Facial:__________________________________________________________________________ Amarilla:_________________________Enrojecida:____________________________________________

IV. SKIN ALTERATIONS Untuosa:___________________Oleosa:__________________Brillosa:____________________________

Nevus:______________________________Cloasma:________________________________________ Black or White Comedones:__________________________________________________________

Petequias:____________________________Papula:________________________________________ Wrinkles and Expression Lines:_________________________________________________________

Vasicula:________________________Comedones:________________________________________ Entrecejos Periorbiculares:_____________________________________________________________

Lentigus:____________________________Cicatriz:________________________________________ Naso Geniano:____________________________________________________________________________

Telegentasia:________________________________________________________________________ Peribucales:_______________________________________________________________________________

Costra:________________________________________________________________________________ VI SKIN BIOTYPE:

Melasma:_____________________________________________________________________________ EUDERMICA O NORMAL:_______________________________________________________________

Milliun:_______________________________________________________________________________ _____________________________________________________________________________________________
_________________________ ______________________

Signature of Patient Cosmeatrist