FICHA DE AVALIAÇÃO

IDENTIFICAÇÃONome:__________________________________________________________________________________Idade:________ sexo ___________Profissão:_______________________Estado Civil__________________Endereço:_______________________________________________Bairro__________________________ Cidade:__________________________________________UF:____________CEP:____________________Fone:________________________ e-mail____________________________________________________Cor da pele: ( ) branca ( ) parda ( ) negra ( ) amarelaPeso:_____________Altura_______________

ANAMNESEQueixa Princaipal:_______________________________________________________________________________Já fez tratamento estético anteriormente? ( ) sim ( )não Porque? _______________________________________________________________________________________ Antecedentes cirúrgicos:___________________________________________________________________Antecedentes alérgicos:____________________________________________________________________Pratica esportes? ( ) sim ( )não . Qual?________________________Freqüência:______________________Faz algum tratamento médico? ( ) sim ( )não. Qual?_____________________________________________Portador de marca-passo? ( ) sim ( )nãoApresenta metais no corpo? ( ) sim ( )nãoFaz uso de medicamentos: à base de corticóides ( ) anti-histamínico( ) esteróides( )Antiinflamatórios( ) outros( ) não faz uso de medicamentos Qual método anticoncepcional usa? _________________________________________________________Tem antecedentes ontológicos?_____________________________________________________________Bebe? ( ) sim ( )não frequncia:_______________________________________________________________Fuma: ( ) sim ( )não Freqüência______________________________________________________________Tipo de alimentação: ( ) Normal ( ) vegetarianaFreqüência de ingesta de liquido por dia:______________________________________________________Transtorno circulatório e /e ou de cicatrização? ( ) sim ( )não______________________________________Diabetes: ( ) sim ( ) não Hemofilia: ( ) sim ( ) nãoPropensão a quelóides: ( ) sim ( ) nãoApresenta algun tipo de disfunção hormonal?__________________________________________________Alergia a: ( ) corrente elétrica ( ) produtosCuidas diários e uso de produtos cosméticos: ____________________________________________________________________________________________ _____________________________________________Usa ou já usou acido na pele? ( ) sim ( )não Qual?______________________________________________Apresenta algum tipo de disfunção hormonal: _________________________________________________Número de gestações:________ _______ Número de filhos_______________________________________Menstruação: ( ) regular ( )irregularFuncionamento do intestino? ( )regulara ( ) irregular freqüência___________________________________É hipertenso? ( ) sim ( ) nãoDe 0 a10 qual seu nível de estresse?__________________________________________________________

EXAME FÍSICOAdiposidade localizada: ( )presente ( ) ausente Região:__________________________Edema : ( )presente ( ) ausente Região:__________________________Micro varizes: ( )presente ( ) ausente Região:__________________________Estrias: ( )presente ( ) ausente Região:__________________________Fibroedemegeloide: Grau ( ) 1 ( )2 ( )3 Região:__________________________

Evolução_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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