MEDICAL AND ESTHETIC CLINICAL RECORD

File No_ RUT _______________________

Date of consultation _______________________

Name______________________________________________________________ Age
___________
Date of birth _____________________ Cellular ____________________
Occupation _____________________________
Dirección ____________________________________________________________
A. REASON FOR THE CONSULTATION

 Envejecimiento_________________  Adiposidad localizada______________

 Arugas_________________________
 Manchas _______________________
 Acné___________________________
 Rosácea_______________________
 Celulitis________________________
 Flaccidez________________________
 Estrías__________________________
 Skin care_________________
 Otros___________________________
__________________________________

B. PATHOLOGIC ANTECEDENTS

Allergies YES ( ) NO ( ) Ho Pregnancies______ Births___

__________________________
Diabetes YES ( ) NO ( )
Respiratory YES ( ) NO ( )
Cardiac YES ( ) NO ( )
Digestive YES ( ) NO ( )
Constipation YES ( ) NO ( )
Edemas YES ( ) NO ( )
Hair loss YES ( ) NO ( )
Pacemaker Holder YES ( ) NO ( )
Metallic prosthesis YES ( ) NO ( )
Contact lenses YES ( ) NO ( )
Ant. Oncologic YES ( ) NO ( )
Cold sores YES ( ) NO ( )
Especifique_________________________
Miscarriages___ Abortions___
Breastfeeding YES ( ) NO ( )
FUM_______________
Método anticonceptivo____________________
Phobias YES ( ) NO ( )
Alt. Glandular YES ( ) NO ( )
Seizures YES ( ) NO ( )
Cancer YES ( ) NO ( )
Varicose veins YES ( ) NO ( )
Hypertension YES ( ) NO ( )
Hypoglycemia YES ( ) NO ( )
Syncope YES ( ) NO ( )
Especifique_____________________________
______________________________________

C. SURGICAL HISTORY.
Aesthetic implants YES ( ) NO ( )
Surgery YES ( ) NO ( )
Remarks ___________________________________________________

C. INGESTS ANY TYPE OF MEDICATION

HANDLE YES ( ) NO ( )
Acenocoumarol YES ( ) NO ( )
Aminoglycoside type antibiotic YES ( ) NO ( )
Vitamin E YES ( ) NO ( )
Fish liver oil YES ( ) NO ( )
Ginkgo Biloba YES ( ) NO ( )

D. HABITS.
Smoke ________________________
Consume alcohol ________________
Solarium ______________________
Sauna_________________________
Ejercicios físicos__________________
Frequent overnights __________
Ingestion of water A lot ( ) Regular ( ) Little ( )
Coffee A lot ( ) Regular ( ) A little ( )

E. SKIN CARE

Cleanses the skin day ________ night ___________

Use day cream ___________________
Use night cream ___________________
Use sunscreen ___________________
Use eye contour ___________________

F. SKIN EVALUATION. CUTANEOUS SEMIOLOGY

Skin Biotype: Normal _____ Dry ______ Oily _____ Mixed ______
Phototype __________________ Glogau ___________________
Pigmentary alteration ________________________________
_______________________________________________________________________________

I. TREATMENT TO BE CARRIED OUT (Specify type of treatment: product, brand, quantity, batch,
expiration date and frequency)

Professional signature.