BELLA NOVA ESTHETICS & SPA

FACIAL DIAGNOSIS CARD

DATE: ____/____/____/____

I. PERSONAL INFORMATION
FIRST AND LAST NAMES: _____________________________________________________________
SEX: ______________ AGE: _______________ DATE OF BIRTH: ____/____/_______
ADDRESS: ___________________________________________ DISTRICT: ________________
PROVINCE: _________________ DEPARTMENT: ______________ EMAIL : _________________
OCCUPATION: ________________________ PHONE: ______________ CELL: ____________
HOW HE ARRIVED AT THE CENTER:
Web page ( ) Facebook ( ) By recommendation ( ) Other: _____________

II. CONFIDENTIAL CUSTOMER INFORMATION

YES NO
 DIABETES ( ) ( ) ( )
 ALLERGIES ( ) ( ) ( )
 PROB. CARDIAC ( ) ( ) ( )
 PROB. RESPIRATORY ( ) ( ) ( )
 CANCER ( ) ( ) ( )
 PREGNANCY ( ) ( ) ( )
 SUFFERS FROM ANY OF THE
FOLLOWING
DISEASE ( ) ( ) ( )
_____________________________
III. FACIAL INFORMATION
SKIN DISORDERS
YES NO
 CONTRACEPTIVE METHODS ( ) ( ) ( )
 TTO. WITH HORMONES ( ) ( )
 CARDIAC PROBLEMS ( ) ( ) ( )
 HYPOTENSION ( ) ( ) ( )
 HYPERTENSION ( ) ( ) ( )
 CONSUMES WATER ( ) ( ) ( )
 CONSUMES MEDICINES ( ) ( ) ( )
 ALCOHOL CONSUMPTION ( ) ( ) ( )
 USES DRUGS ( ) ( ) ( )

 NEVUS ( )  PUSTULA ( )
 MARK ( )  TELAGIECTASIAS ( )
 ACNE ( )  MILLIUM ( )
 CYCLES ( )  EFELIDES ( )
 DESQUAMATION ( )  OTHER ( )
 PÁPULA ( )

APPEARANCE OF THE SKIN

 PORES Open ( ) Open ( ) Contracted ( ) Semi visible ( )

 TEXTURE Thin ( ) Medium ( ) Coarse ( )
Flexible ( ) Tight ( ) Sticky ( ) Unctuous ( )
 COLOR White ( ) White ( ) Black ( ) Black ( ) Pale ( ) Pale ( ) Reddish ( ) Opaque ( )
 COMEDONS : Blacks ( ) Whites ( )
 EXPRESSION LINES : __________________________________________________________
 WRINKLES Eye orbicularis ( ) Nasolabial ( ) Frontalis ( ) Lips ( )

SKIN DIAGNOSIS (BIOTYPE)

NORMAL ( ) OILY ( ) DRY ( ) MIXED ( )

PROPENSA: __________________________________________________________________
BELLA NOVA ESTHETICS & SPA

PRODUCTS CURRENTLY IN USE: ___________________________________________

DATE PRODUCT ACTIVE PURPOSE

CLIENT ACCEPTANCE: THE COSMIATRIST IS NOT RESPONSIBLE FOR HIDDEN DATA IN YOUR
HISTORY, REMEMBER THAT ANY COMPLICATION OR LACK OF RESULTS WITHIN THE
TREATMENT OR AFTER IT, RELATED TO DISEASES OR RELEVANT HEALTH INFORMATION, ARE
STRICTLY THE RESPONSIBILITY OF THE PATIENT.
I SIGN IN CONFORMITY THAT ALL THE ABOVE DATA PROVIDED BY ME ARE TRUE _____________________
DNI _____________________
BELLA NOVA ESTHETICS & SPA

IV. CUSTOMER RECOMMENDATIONS

1. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. ______________________________________________________________________________
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5. ______________________________________________________________________________
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_______________________________ _______________________________
SIGNATURE CLIENT SIGNATURE COSMIATRIST SIGNATURE
NAMES: _____________________ NAMES: _____________________
DNI: __________________________ DNI: __________________________

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