Piel Seca:_____________________Piel Hidratada:___________________________________________

Atypische trockene Haut:________________Senile trockene

Haut:_______________________________________

Fettige Haut:_______________________Fettige, asthmatische

Haut:________________________________

Piel Grasa Sensible:_____________________________________________________________________

Seborrhoische fettige Haut

Affluent:________________________________________________________

Combination Skin and

Acne:________________________________________________________________________

VII. DIAGNOSE:
DIAGNOSEBOGEN
_____________________________________________________________________________________________
I PERSONENBEZOGENE DATEN
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Nombres y
Apellidos:__________________________________________________________________________
VII. BEHANDLUNG: CHEMISCHES ABZIEHEN Fecha de Nacimiento:_____________________________________________________________
_____________________________________________________________________________________________ Estado Civil:_______________________________________________________________________
_____________________________________________________________________________________________
Direcció n:__________________________________________________________________________
_____________________________________________________________________________________________
Teléfono:___________________________________________________________________________
DATUM CHEMISCHES TOLERANZZEIT EFFEKT Correo Electró nico:_______________________________________________________________
PRODUKT
Tratamiento:______________________________________________________________________

Profesió n:__________________________________________________________________________
II. PATHOLOGISCHE DATEN V. EIGENSCHAFTEN

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. ÄSTHETISCHE OPERATIONEN Blefaroplastia:________________________________________________________________________

Rinoplastia:____________________________________________________________________________ Liftin Facial:__________________________________________________________________________

Abdominoplastia:_____________________________________________________________________ IV. HAUTVERÄNDERUNGEN

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

Petequias:____________________________Papula:________________________________________ Schwarze oder weiße

Komedonen:__________________________________________________________
Vasicula:________________________Comedones:________________________________________
Fä ltchen und Mimikfalten:_________________________________________________________
Lentigus:____________________________Cicatriz:________________________________________
Entrecejos Periorbiculares:_____________________________________________________________
Telegentasia:________________________________________________________________________
Naso Geniano:____________________________________________________________________________
Costra:________________________________________________________________________________
Peribucales:_______________________________________________________________________________
Melasma:_____________________________________________________________________________
VI HAUTBIOTYP:
Milliun:_______________________________________________________________________________
EUDERMICA O NORMAL:_______________________________________________________________
Acne:_________________________________________________________________________________
_____________________________________________________________________________________________
Textura Opaca:____________________________________________________________________________
_________________________ ______________________
Poros cerrados:_______________________Dilatados:_________________________________________
Unterschrift des Patienten Kosmeztin
Poco Visible: ______________________________________________________________________________

Color Rosada:_________________________Palida:_____________________________________________

Gris:_____________________________Amarillenta:____________________________________________

Amarilla:_________________________Enrojecida:____________________________________________