HISTORIA DE COSMETOLOGIA

FECHA:_____________________________
NOMBRE COMPLETO _________________________________________________________
MOTIVO DE CONSULTA_____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
CLASIFICACION PIEL
Normal
Alipica
Mixta
Grasa
Acn

GRADO

AREA COMPROMETIDA

Tipo:

ANTECEDENTES PERSONALES: ______________________________________________________

_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
LESIONES CUTANEAS
SI

NO

Comedones abiertos
Comedones cerrados
Ppulas
Pstulas
Quistes de Millium
Queratosis
Cicatrices SI__ NO__

SI

NO

Acromias
Hipercromas
Hipocromas
Eflides
Herpes
Dermatitis
Atrficas

Hipertrficas

Queloide

Adheridas

OBESERVACIONES:___________________________________________________________________
_______________________________________________________________________________________________
_____________________________________________________________________
TRATAMIENTO DE CABINA: ____________________________________________________________
__________________________________________________________________________________

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
TRATAMIENTO DOMICILIARIO:________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

______________________
Firma Del Paciente

__________________________
Firma Profesional

HISTORIA N___________________ NOMBRE COMPLETO______________________________

FECHA

TRATAMIENTO

OBSERVACION

PROFESIONAL

USUARIO