Kassia Spa

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FACIAL DATA SHEET

FECHA:___________________________________________________
1. PERSONAL DATA
Nombres y Apellidos:_________________________________________________________________________
Date of birth:_____________________ Age:______ # Children :_____ EPS:_______________________
Dirección:__________________________________________________ E- mail:_________________________
Ocupación:________________________________ Teléfonos:________________________________________

2. REASON FOR CONSULTATION

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3. CLINICAL DATA
a. FAMILY ILLNESSES
Diabetes Asthma Hypertension Cancer Other
Cuál__________________________________
b. PERSONAL ILLNESSES
Enfermedades que ha padecido:_______________________________________________________________
Enfermedades que padece actualmente:________________________________________________________
Medicamentos que esté tomando:_____________________________________________________________
Planning method (women)____________________________________________________________
Use of prosthesis: Dental Contact lenses None

4. AESTHETIC DATA
a. IMPLANTS OR GRAFTS
Chin Cheeks Nose None
b. COSMETIC SURGERIES AND AESTHETIC TREATMENTS
Blepharoplasty Rhinoplasty Bichectomy None
Otoplasty Lifting Septoplasty
c. COSMETIC PROCEDURES
Application Acid Plasma Vitamin None
of Autologous Hyaluronic Botox C
Hace cuánto tiempo?_______________________________________________

5. Aesthetic Analysis
a. COLOR DE PIEL__________________________________________________________________________
b. TIPOLOGÍA CUTÁNEA____________________________________________________________________
Normal Skin Combination Skin Dry Skin Oily Skin
Asphyxiated Skin Devitalized Skin Hydrated Skin
c. DEGREE OF DEHYDRATION
Slight Medium High
d. SKIN THICKNESS
Thin Medium Thin Medium Medium Medium Thick Thick Thick
e. SKIN PATHOLOGIES
Erythema Telangiectasias Papules Melasma Hyperpigmentations
Blisters Couperosis Pustules Pustules Wrinkles Vascular Stars
Vesicles Scars Cysts Mycosis Dermatitis of Berloque
Angiomas Crusts Millium ephelides Hirsutism
Comedones Verruca Nevus Keratosis Urticaria
Eczema Nodules Vitiligo
f. ACNE TENDENCY YES NO Type of Acne__________________________________

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g. PRODUCT ALLERGY
Makeup Moisturizing Cream Nourishing Cream Other None
Cuál?____________________________________________________________________________________
Specific active ingredients: honey strawberry grape almonds Other None
Cuál?____________________________________________________________________________________
h. PROCEDURE TO BE PERFORMED
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6. GENERAL OBSERVATIONS
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7. LEGAL COMMITMENT
I ____________________________________________________________ identified with citizenship card N°
_____________________ certify that the information provided here is true; I authorize the beautician to
perform the following treatment ______________________________________________________________. I
know all its effects and contraindications, I accept the suggested recommendations and I exempt
____________________________________________________ from any responsibility for any alteration that
may occur due to the treatment to be performed.

USER SIGNATURE SIGNATURE ESTHETICIAN SIGNATURE

CC NO. CC NO.

8. ANNEXES

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FECHA:__________________________

TRATAMIENTO A REALIZAR_______________________________________________________________
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TRATAMIENTO REALIZADO________________________________________________________________
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OBSERVACIONES___________________________________________________________________________
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USER SIGNATURE SIGNATURE ESTHETICIAN SIGNATURE

CC NO. CC NO.

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g. PRODUCT ALLERGY
Makeup Moisturizing Cream Nourishing Cream Other
Cuál?____________________________________________________________________________________
Specific active ingredients: honey strawberry grape almonds Other
Cuál?____________________________________________________________________________________
h. PROCEDURE TO BE PERFORMED
_________________________________________________________________________________________
6. GENERAL OBSERVATIONS
__________________________________________________________________________________________
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____________________________________________________________________________________________
____________________________________________________________________________________________
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_____________________________________________________________________________________________
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___________________________________________________________________________________________
7. LEGAL COMMITMENT
I ____________________________________________________________ identified with citizenship card N°
_____________________ certify that the information provided here is true; I authorize the beautician to
perform the following treatment ______________________________________________________________. I
know all its effects and contraindications, I accept the suggested recommendations and I exempt
____________________________________________________ from any responsibility for any alteration that
may occur due to the treatment to be performed.

USER SIGNATURE SIGNATURE ESTHETICIAN SIGNATURE

CC NO. CC NO.