Anamnese de Simetria Facial Nome da(o) cliente ou responsável:___________________________________________ Nasc:___/___/____Endereço:_______________________________________________ Nº:______________Bairro:_________________________Cidade:__________________ Tel.Res:________________________Cel:_____________________________________ Profissão:__________________________Indicação:_____________________________ Facebook: ______________________________________________________________ Outros: _________________________________________________________________ Preenchimento do cliente: Tem crescimento de pelos sim ( ) não ( ) Queda de pelos na sobrancelha sim ( ) não ( ) Queda nos cílios sim ( ) não ( ) Está Grávida sim ( ) não ( ) Está amamentando sim ( ) não ( ) Falhas nas sobrancelhas sim ( ) não ( ) Falhas nos cílios sim ( ) não ( ) Alergia sim ( ) não ( ) a quê?_____________________________ Preenchimento do profissional (Medidas) : TO (tamanho do olho) ________________________________________________ Glab (espaço entre os olhos)____________________________________________ PC (ponto central)____________________________________________________ PMA (ponto mais alto)________________________________________________ TS (tamanho da sobrancelha)___________________________________________ ALT.IN (altura do início da sobr.)________________________________________ ALT.PMA (altura do ponto mais alto)_____________________________________ ALT.F (altura do final da sobr.)__________________________________________ E.IN (espessura do início das sobr.)_______________________________________ EPMA (espessura do ponto mais alto)____________________________________ E.PMA..F (espessura entre o ponto alto e o final)____________________________ Volume (rala, cheia) __________________________________________________ _____________________________________ Ass. do cliente ou Responsável Anotações 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