4 курс / Дерматовенерология / karta
.doc
ИНДИВИДУАЛЬНАЯ КАРТА КЛИЕНТА
Фамилия, имя:_________________________________________________________________________
Пол: мужской, женский
Дата рождения:________________________________________________________________________
Профессия:_____________________________________________________________________________
Телефон:________________________________________________________________________________
e-mail:___________________________________________________________________________________
АНАМНЕЗ
Инфекционные заболевания (Гепатит, ВИЧ, ТВС)_______________________________
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Аллергические реакции (на медикаменты, продукты пчеловодства)
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Гинекологический анамнез (миомы, гормональный фон, регулярность менструаций)___________________________________________________________________________
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Эндокринная сфера (щитовидная железа, сахарный диабет)
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Дерматологический анамнез (нейродермит, экзема, грибковые заболевания)____________________________________________________________________________
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Другие заболевания____________________________________________________________________
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Какие процедуры получали ранее __________________________________________________
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Косметика в домашнем уходе _______________________________________________________
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умывание________________________________________________________________________
маски_____________________________________________________________________________
кремы, серум____________________________________________________________________
Какие салонные процедуры Вас интересуют _____________________________________
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Дата Подпись
РЕКОМЕНДАЦИИ
(домашний, салонный уход)
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ЗАМЕТКИ
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