1

FICHA N _____________

DATA: ____/____/______

DADOS DO CLIENTE

HORA: ___:___

CADASTRO N

Nome:
Endereo: ________________________________________________________________
______________________________ Bairro _____________________________________
N__________ Cidade ________________________________ UF ___________________
Complemento _____________________________________________________________
__________________________________ E-mail _________________________________
Telefone: (___) _________________________ Celular: (___)________________________
Estado Civil:

Casado(a)

Solteiro(a) Possui Filhos?

Sim

No ________________

Data de nascimento: ____/____/_____ Data da ltima menstruao: ___/____/______

Ciclo Menstrual:

Regular

Irregular H suspeita de gravidez?

Usa mtodos contraceptivos?

Faz reposio hormonal?

Sim

Sim

Hiperlipdica

No Possui ovrios policsticos?

No Alguma disfuno da tireide?

Visita regularmente o ginecologista?

alimentao balanceada?

Sim

Sim

Sim

Hipercalrica

Hipersdica Funcionamento do Intestino

Sim

Sim
Sim

No
No

No Possui bons hbitos alimentaresfaz

No Alimentao:

Costuma dormir aps se alimentar?

No _____

Regular

Hiperglicmica
Irregular ___

No Caso afirmativo, qual tempo e a

frequncia? _______________________________________________________________
Ingesto diria de gua:

Nenhuma

Muito pouca

Pouca

Menos que 8 copos/dia

Mais que 8 copos/dia Ingesto de outros lquidos:

Sucos

Refrigerantes

Caf Quantas vezes urina por dia?

Faz uso de algum diurtico?

Sim

_____________________________
No Possui problemas renais?

Sim

Chs
No sei
No ____

_________________________________________________________________________
Desenvolvido por: Portal Esteticistas | Site: www.portalesteticistas.com.br | Facebook: facebook.com/PortalEsteticistas

Possui problemas cardacos?

Presso arterial:

Alta

Possui marca-passo?

Sim

Baixa
Sim

No Caso afirmativo, identifique quais a seguir:

Normal Obs.: _______________________________

No Obs.: _____________________________________

Apresenta algum problema circulatrio?

Tem diabetes?

Sim

Sim

No Obs.: ____________________

No Fez algum tratamento esttico anterior?

Sim

No

Em caso positivo, qual foi o tratamento e em qual data? ___________________________

_________________________________________________________________________
______________________________________________________Data: ____/____/_____
Costuma tomar sol?

Sim

No Usa prtese dentria?

Sim

No

Utiliza algum

produto cosmtico? _______________________________________________________

Pratica alguma atividade fsica
Moderada

Sim

No Caracterize a atividade fsica em:

Intensa Quanto tempo dorme por dia?

8h/dia

Leve

Menos de 8h/dia

Mais de 8h/dia Obs.: ___________________________________________________

Utiliza ou j utilizou algum cido?
Faz uso de algum psicotrpico?
Tabagismo:

Sim

Sim
Sim

No Qual: ________________________
No Usa lentes de contato?

Sim

No

No Frequncia: ______________________________________

J passou por interveno cirrgica?

Sim

No Caso afirmativo, quais e em qual pe-

rodo da vida: ______________________________________________________________

_________________________________________________________________________
________________________________________________________________________
Faz algum tratamento mdico no momento?

Sim

No Caso afirmativo, informe o

tratamento: _______________________________________________________________
________________________________________________________________________
Possui antecedentes oncolgicos?

Sim

No Obs.: __________________________

________________________________________________________________________
Alguma doena no mencionada? _____________________________________________
_________________________________________________________________________
_________________________________________________________________________
Desenvolvido por: Portal Esteticistas | Site: www.portalesteticistas.com.br | Facebook: facebook.com/PortalEsteticistas

AVALIAO DA PELE
CARACTERSTICAS CUTNEAS
MANCHAS PIGMENTARES RELACIONADAS MELANINA

PRESENA
ACROMIA

CLOASMA

EFLIDES

HIPERCROMIA

HIPOCROMIA
_______________________________________________________
MANCHAS POR ALTERAES VASCULARES

ANGIOMA

CIANOSE

ERITEMA

HEMATOMA

TELEANGECTASIAS
_______________________________________________________
FORMAES SLIDAS

CERATOSE

PPULAS

NDULOS

VERRUGAS

MILLIUM
NECROSE
COMEDO
_______________________________________________________
FORMAES COM CONTEDO LIQUDO

BOLHA

PSTULA

VESCULA

_______________________________________________________
_______________________________________________________
LESES DE PELE

CROSTA

DESCAMAO

ESCARA

FISSURA

FSTULA

ESCORIAO
ULCERAO
_______________________________________________________
SEQUELAS

ATROFIA

CICATRIZ

_______________________________________________________
_______________________________________________________
PELOS

HIPERTRICOSE

ALTERAES DE QUERATINIZAO

ECZEMA

HIRSUTISMO

HIPERQUERATOSE

PSORASE

_______________________________________________________
_______________________________________________________
CLASSIFICAO DO FOTOTIPO CUTNEO

FOTOTIPO I

FOTOTIPO II

FOTOTIPO V
QUANTO HIDRATAO

FOTOTIPO III

FOTOTIPO IV

FOTOTIPO VI

DESIDRATADA

NORMAL

_______________________________________________________
_______________________________________________________
QUANTO AO GRAU DE OLEOSIDADE

ALPICA

LIPDICA

NORMAL

SEBORREICA

_______________________________________________________
_______________________________________________________
QUANTO ESPESSURA

ESPESSA

FINA

MUITO FINA

_______________________________________________________
_______________________________________________________
Desenvolvido por: Portal Esteticistas | Site: www.portalesteticistas.com.br | Facebook: facebook.com/PortalEsteticistas

PLANO DE TRATAMENTOS
TRATAMENTOS E DETALHAMENTO
_____________________________________________________
_____________________________________________________

CALENDRIO

Ms____________
SEG

TER

QUA

QUI

SEX

SB

DOM

SEX

SB

DOM

SEX

SB

DOM

SEX

SB

DOM

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________
SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________
SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________

_____________________________________________________
_____________________________________________________

SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Desenvolvido por: Portal Esteticistas | Site: www.portalesteticistas.com.br | Facebook: facebook.com/PortalEsteticistas

PLANO DE TRATAMENTOS
TRATAMENTOS E DETALHAMENTO
_____________________________________________________
_____________________________________________________

CALENDRIO

Ms____________
SEG

TER

QUA

QUI

SEX

SB

DOM

SEX

SB

DOM

SEX

SB

DOM

SEX

SB

DOM

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________
SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________
SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________

_____________________________________________________
_____________________________________________________

SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Desenvolvido por: Portal Esteticistas | Site: www.portalesteticistas.com.br | Facebook: facebook.com/PortalEsteticistas

PLANO DE TRATAMENTOS
TRATAMENTOS E DETALHAMENTO
_____________________________________________________
_____________________________________________________

CALENDRIO

Ms____________
SEG

TER

QUA

QUI

SEX

SB

DOM

SEX

SB

DOM

SEX

SB

DOM

SEX

SB

DOM

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________
SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________
SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Ms____________

_____________________________________________________
_____________________________________________________

SEG

TER

QUA

QUI

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Desenvolvido por: Portal Esteticistas | Site: www.portalesteticistas.com.br | Facebook: facebook.com/PortalEsteticistas

OBSERVAES DO PROFISSIONAL ESTETICISTA

OBSERVAES: ____________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

ASSINATURAS
CIDADE:__________________________________________UF______ DATA: ____/____/______

_________________________________________________
CLIENTEN DO RG________________________

_________________________________________________
PROFISSIONAL ESTETICISTA

Desenvolvido por: Portal Esteticistas | Site: www.portalesteticistas.com.br | Facebook: facebook.com/PortalEsteticistas