FACIAL COSMETIC CARD Date: / /

Name:.......................................................................................................................DNI:.................................
Address:...........................................................................................City..........................................................
CP:...................................................cell:..................................@...............................................................
Sex:.................................Date of birth:.......................................Occupation:..................................................
Reason for consultation:...................................................................................................................................
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A.General Background
Drug allergy: .................................................................................................................................................
Allergy to: anesthetics ........................cosmetics ..............................perfumes .............................
Others...............................................................................................................................................................
Does it bruise easily?........................................................................................................................................
Medication you are currently taking:.................................................................................................................
Daily activities: work:................................................................Rest................................................................

General life method

Habits: sun ............................... tobacco ..................................... alcohol .......................................
Tranquilizers ..........................................skin protection .......................................................................
Usual diet ................................................................sports ....................................................................
Ingestion of liquids ..................................................Others.........................................................................
Are you taking or have you ever taken: corticosteroids
......................................................................................antidepressants ....................................................
Hormonal contraceptives ...................................vitamin A acid, acidic ac. Retinoic acid or tretinoin ...
Diuretics ......................................................................................................................................................
Carotenes or other pigments ......................................................................................................................
Others...............................................................................................................................................................
Do you suffer or have you suffered from any skin disease?.............................................................................
Diabetes?........................Hormonal diseases?................................................................................................
What is the menstrual cycle like?.....................................................................................................................
Other current diseases under medical treatment:.............................................................................................
Suffering from: cellulite ............obesity ..............................flaccidity ..................varicose veins
Other aesthetic conditions?..............................................................................................................................

B.Aesthetic background
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Aesthetic and plastic operations.......................................................................................................................
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 C.Current data interrogation
Is this your first visit?.....................Is this your first skin hygiene? ...................................................................
Do you use cosmetics?.....................................................................................................................................
Cleaning .......................................Lotion ..................................moisturizer ....................................
Do you suffer from skin discomfort?....................Heat .......................................burning ......................
Tightness .................................sensation of dryness ............................................................................

D.Skin examination. Diagnosis of skin biotype (to be completed by the professional)

Observation Palpation
Front.......................................................................Front..................................................................................
Nose ......................................................................Nose..................................................................................
Chin ......................................................................Chin...................................................................................
Cheeks ..................................................................Cheeks...............................................................................
Collar.....................................................................Collar.................................................................................
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It is noted:
Dehydration .................................................................................................................................................
Alipia ...........................................................................................................................................................
Telangiectasias ........................Couperosis or erythrosis .....................................................................
Erythema .................................hyperkeratosis ....................................................................................
Pigmented macules........................................Location....................................................................................
Form..............................................................................................size............................................................
Annoyance caused by...................................................................Evolution....................................................
Vascular macules (angiomas, telangiectasias, ruby spots)..............................................................................
Location.........................................................................................form............................................................
Size................................................................................................inconvenience caused by..........................
Evolution...........................................................................................................................................................
Sebaceous secretion: scanty ............ normal ......... seborrheic ...........hyperseborrheic .........
Pores: small ...............................dilated ...............................very dilated ........................................
Comedones ..............................................................Papules ..............................................................
Pustules .....................................................................scars ..................................................................
Diagnosis of facial skin biotype.........................................................................................................................
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E.Cabinet proposal (to be completed by the professional)
Hygiene Peeling ....................................................................................................................................
Rejuvenation ........................................................Hydration ................................................................
Acne .....................................................................Rosacea ..................................................................
Depigmenting .......................................................Emollient .................................................................
Appliances ..................................................................................................................................................
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