FACIAL CLINICAL HISTORY

Date of consultation: Day: _______ Month: _______ Year: _______ Medical history No.___________________
Reason for consultation: ___________________________________________________________________________
Diagnosis: __________________________________________________________________________________
Treatment: __________________________________________________________________________________
_______________________________________________________________________________________________
Sessions: _____________________________ No. Sessions: ___ 1___ 2___ 3___ 4___ 5___ 6___ 7___ 8___

Name and surname: ________________________________________________ ID No. ________________

Age: ______ Date of birth: Day: ______ Month: ______ Year: _______ No. Of Children: ______
Type of delivery: ________________________________________________________________________________
Occupation or trade: _______________________________ Address: _________________________________
Contact phone: _____________________________ WhatsApp: _______________________________
Email:
_______________________________________________________________________________________________
_______

TO. PATHOLOGICAL HISTORY

Diabetes ______________
Respiratory _____________
Cardiac _______________ Seizures ____________
Digestives _______________ Cancer ____________
Constipation _______________ Varicose veins ____________
Liquid retention _______________ Hypertension _____________
Renal insufficiency _______________ Hypoglycemia ____________
Pregnancy _____________

Last period date _____________________

b. SURGICAL HISTORY .

Platens ____________________
Pacemaker ____________________
Aesthetic implants ____________________
Surgery ____________________
Observations _________________________________________________

c. INGEST SOME TYPE OF MEDICATION

d. HABITS.
Smokes ________________
Consumes alcohol ________________
Plan ________________
Stay up late frequently ________________

(M=a lot, R=regular, P=a little)

Drink water ______________
(M=a lot, R=regular, P=a little)
Drink coffee ______________

AND. SKIN CARE

Cleanse the skin day ________ night ___________

Use ______________ toner

Use ___________________ day cream

Use night cream ___________________

Use sunscreen ___________________
Use ___________________ eye contour

F. SKIN EVALUATION

g. RECOMMENDED PRODUCTS FOR THE HOUSE.

1.___________________________ 3.________________________
2.___________________________ 4.________________________

H. PRODUCTS YOU BRING TO THE HOUSE

___________________________ Date____________________________
___________________________ Date____________________________

YO. TREATMENT TO BE PERFORMED (Specify type of treatment and weekly or monthly frequency)
______________________________ __________________________

Patient signature Professional signature.