Ficha de Avaliação – Fundamentos do Cabelo
Data: ____/____/______.
01) Identificação
Nome: _________________________________________________________________
Data de Nascimento: ____/____/______.
Profissão: ________________________
Uso de Medicamentos: ( ) corticóides ( ) anti-histamínicos ( ) antinflamatórios
( ) esteróides ( ) outros
02) Diagnóstico Capilar
Couro Cabeludo
Presença de Alopecia: ( ) sim ( ) não
Qual?__________________________________________________________________
Oleosidade: ( ) baixa ( ) média ( ) alta
Fio de Cabelo
Elasticidade: ____________________________________________________________
Porosidade: ____________________________________________________________
Densidade______________________________________________________________
Forma: ( ) Liso
( ) Crespo ( )
Negróide
( ) Ondulado
Espessura: ______________________________________________________________
Cores: ( ) Quentes
( ) Frias
Tratamento Proposto:
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Avaliação realizada por: ___________________________________________________