Piel Seca:_____________________Piel Hidratada:___________________________________________

Peau sèche atypique:________________Peau sèche

sénile:_______________________________________

Peau grasse:_______________________Peau grasse

astiquée:________________________________

Piel Grasa Sensible:_____________________________________________________________________

Peau grasse séborrhéique Affluent :

________________________________________________________

Combination Skin and

Acne:________________________________________________________________________

VII. DIAGNOSTIC :
FICHE DE DIAGNOSTIC
_____________________________________________________________________________________________
I DONNÉES PERSONNELLES
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Nombres y
Apellidos:__________________________________________________________________________
VII. TRAITEMENT : DÉPELLICULAGE CHIMIQUE Fecha de Nacimiento:_____________________________________________________________
_____________________________________________________________________________________________ Estado Civil:_______________________________________________________________________
_____________________________________________________________________________________________
Direcció n:__________________________________________________________________________
_____________________________________________________________________________________________
Teléfono:___________________________________________________________________________
DATE PRODUIT TEMPS DE EFFET Correo Electró nico:_______________________________________________________________
CHIMIQUE TOLÉRANCE
Tratamiento:______________________________________________________________________

Profesió n:__________________________________________________________________________
II. DONNÉES PATHOLOGIQUES V. CARACTÉRISTIQUES

DIABETES:______________________________________________________________________________ Textura Gruesa:___________________________________________________________________________

CANCER:________________________________________________________________________________ Textura Delgada:__________________________________________________________________________

ASMA:___________________________________________________________________________________ Textura Aspera:___________________________________________________________________________

PROBLEMAS HORMONALES:_________________________________________________________ Textura Lisa y Fina:_______________________________________________________________________

CIRUGIA RECIENTE:___________________________________________________________________ Textura Granulosa:_______________________________________________________________________

Antibioticos:____________________Alcohol:__________________Tabaco:___________________ Implantes Faciales:___________________________________________________________________

III. CHIRURGIES ESTHÉTIQUES Blefaroplastia:________________________________________________________________________

Rinoplastia:____________________________________________________________________________ Liftin Facial:__________________________________________________________________________

Abdominoplastia:_____________________________________________________________________ IV. ALTÉRATIONS DE LA PEAU

Nevus:______________________________Cloasma:________________________________________ Untuosa:___________________Oleosa:__________________Brillosa:____________________________

Petequias:____________________________Papula:________________________________________ Comédons noirs ou blancs : __________________________________________________________

Vasicula:________________________Comedones:________________________________________ Rides et rides d'expression : _________________________________________________________

Lentigus:____________________________Cicatriz:________________________________________ Entrecejos Periorbiculares:_____________________________________________________________

Telegentasia:________________________________________________________________________ Naso Geniano:____________________________________________________________________________

Costra:________________________________________________________________________________ Peribucales:_______________________________________________________________________________

Melasma:_____________________________________________________________________________ VI BIOTYPE DE LA PEAU :

Milliun:_______________________________________________________________________________ EUDERMICA O NORMAL:_______________________________________________________________

Acne:_________________________________________________________________________________ _____________________________________________________________________________________________

Textura Opaca:____________________________________________________________________________ _________________________ ______________________

Poros cerrados:_______________________Dilatados:_________________________________________ Signature du patient Cosméatriste

Poco Visible: ______________________________________________________________________________

Color Rosada:_________________________Palida:_____________________________________________

Gris:_____________________________Amarillenta:____________________________________________

Amarilla:_________________________Enrojecida:____________________________________________