Kulit Kering:_____________________Kulit Lembab:__________________________________________

Kulit Kering Atipikal:________________Kulit Kering

Pikun:__________________________________________

Kulit Berminyak:___________________Kulit Berminyak

Astikasi:________________________________

Kulit Berminyak
Sensitif:__________________________________________________________________________

Kulit Berminyak Seboroik

Berminyak:_____________________________________________________________

Kulit Kombinasi dan

Jerawat:_______________________________________________________________________________

VII. DIAGNOSA: LEMBAR DIAGNOSTIK

_____________________________________________________________________________________________ I. DATA PRIBADI

_____________________________________________________________________________________________ Nama dan
_____________________________________________________________________________________________ marga:____________________________________________________________________________

Tanggal lahir:_____________________________________________________________
VII. PENGOBATAN: UNEPEELING KIMIA
Status sipil:_______________________________________________________________________
_____________________________________________________________________________________________
Alamat:__________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________ Telepon:___________________________________________________________________________

Surel:_______________________________________________________________
TANGGAL PRODUK KIMIA WAKTU MEMENGARUHI
TOLERANSI Perlakuan:______________________________________________________________________

Profesi:__________________________________________________________________________
II. DATA PATOLOGIS
DIABETES:______________________________________________________________________________
KANKER:________________________________________________________________________________
ASMA:___________________________________________________________________________________
MASALAH HORMON:______________________________________
BEDAH BARU-BARU: __________________________________________________________________
ay. KARAKTERISTIK
Antibiotik:___________________Alkohol:__________________Tembakau:___________________
AKU AKU AKU. BEDAH KOSMETIK
Rinoplasti:____________________________________________________________________________
Tekstur
Kasar:_______________________________________________________________________________
Tekstur
Tipis:_______________________________________________________________________________
Tekstur
Kasar:_______________________________________________________________________________
Tekstur Halus dan Halus:_____________________________________________________
Tekstur
Berbutir:______________________________________________________________________________
Abdominoplasti:__________________________________________________________________________
Implan Wajah:_____________________________________________________
Blefaroplasti:________________________________________________________________________
Pengencangan
wajah:____________________________________________________________________________
IV. PERUBAHAN KULIT
Nevus:______________________________Kloasma:____________________________________
Petechiae:_________________________Papula:________________________________________
Vasula:________________________Komedo:________________________________________
Lentigus:_________________________Bekas Luka:________________________________________
Telegentasia:__________________________________________________________________________
Kerak:________________________________________________________________________________
Melasma:__________________________________________________________________________________
Juta:_______________________________________________________________________________
Jerawat:_________________________________________________________________________________
Tekstur
Buram:_________________________________________________________________________________
Pori-pori
tertutup:_____________________________Melebar:_________________________________________
Terlihat buruk:
______________________________________________________________________________
Warna Pink :_________________________Pucat :_____________________________________________
Abu-abu:_____________________________Kuning:_____________________________________________
Kuning merah:_____________________________________________
Berbahaya:___________________Berminyak:__________________Berkilau:____________________
____________________
Komedo Hitam atau Putih:____________________________________________________________
Kerutan dan Garis Ekspresi:_____________________________________________________
Alis periobik:__________________________________________________________________
Naso Genius:_______________________________________________________________________________
Peribukal:_______________________________________________________________________________
VI BIOTIPE KULIT:
EUDERMIC ATAU
NORMAL :_______________________________________________________________
_____________________________________________________________________________________________
_________________________ ______________________
Tanda Tangan Pasien Cosmeatrist