Electrology -Health History Form

Electrology-Health History Form

Primary Information
Client Name*

First NameLast Name
Preferred First Name
Optional
Birth Date*

MonthDayYear
Gender Identified as:
(optional)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone
HOME (Landline)
Phone*
MOBILE
Email Address*
Emergency Contact: First Name Last Name Area Code* Phone Number*
Relationship-Emergency Contact *
How did you hear about us?*
If referral, by who?
[ HEAD ] Areas being considered for treatment: (Select all that apply)*

NONEChinLip/ MustacheNeckBeardEyebrowsUni-BrowSideburnsNoseEarsHairlineOther
[ BODY ] Areas being considered for treatment: (Select all that apply)*

NONEBreastUnderarmsChestBikini LineNavelLabiaTesticlesPenisUpper BackLower backSagittal (hair between navel & pubic area)ButtocksAnusOther
[ LIMBS ] Areas being considered for treatment: (Select all that apply)*

NONEShouldersUpper ArmsLower ArmsHandsFingersOuter ThighsInner ThighsLower LegsToesOther
Hair Removal Methods
What types of TEMPORARY hair removal methods do you frequently use? (Select all that apply)

ShavingWaxingTweezing/ PluckingThreadingDepilatoryDermaplaning
Have you ever had LASER hair removal before?*

YESNO
Approximate date of last LASER treatment

MonthDayYear
Date
Laser Hair Removal Company
Area/s or body parts treated:
List any skin reactions from LASER hair removal treatments received
Have you ever had ELECTROLYSIS before?*

YesNo
Electrologist's Name/ Company
Area/s or body parts treated:
Approximate date of last ELECTROLOGY treatment

MonthDayYear
Date
Total number of treatments:
Skin reactions from ANY previous hair removal methods? (Select all that apply)

NoneRednessSwelllingIngrown hairInfectionBumps/ PimplesScabsOther
Sudden onset of hair growth?*

YesNo
If yes, please describe...
SKIN/ HEALTH INFORMATION
Do you currently or have you used in the last 3 months: Retin-A, Renova, AHA's, or Retinol/Vitamin A derivative products?*

YESNO
Have you received Botox, Restylane, or Collagen injections in the last 6 months on the area receiving electrolysis?*

YESNO
Date of last Botox, Restylane, or Collagen injection service

MonthDayYear
Date
Have you had micro-needling in the last 6 months?*

YESNO
Date of last Microneedling service

MonthDayYear
Date
Personal Health Information

* If no allergies or medications, enter "NONE"
List ALL Allergies
List all medications you are currently taking:
Health Conditions Past or Present: ( select all that appply)*

NONEAcneBreathing Problems/ COPDCancerEars (Hearing aids, Vertigo, Inner ear problems)Blood clotting IssuesPigment ProblemsDissiness/ FaintingCardiovascular DiseaseHeart Surgery (incl: Stint,Pacemaker/Defribulator)Metal ImplantsPCOS/ Infertilty (Polycystic Ovarian Disease)Thyroid DiseaseEndocrine DisordersCold sores/ Fever Blisters (Herpes Simplex)STD's (HIV, Genital Herpes, Chlamidia, HPV/warts ,etc.)TuberculosisDiabetesBody Piercings (other than ears)Other
Have you had any major surgeries?*

YESNO
If yes, please specify:
Are you pregnant?*

YESNO
Do you get your period?*

YESNO
Is it regular?

YESNO
Covid-19 Exposure/ Symptoms?*

YESNO
If you answered YES to any questions in this section, please explain:
Include any important health information not included in the questions above
Gender Affirming Care

(Only complete this section if applicable)
Are you preparing for sex reassignment surgery?

YESNO
Planned date of surgery

MonthDayYear
Date
Physician's Name

First NameLast Name
Physician's Phone Number

Area CodePhone Number
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
May we contact your physician to discuss your treatment plan?

YESNO
Client Acknowledgement of Information

* Please read both PDF documents
REQUIRED: Electrolysis-Prep PDF *
REQUIRED Post -Treatment Care PDF *
How to click "I agree" boxes

Instructions: * Hover cursor on lower right corner of agreement box * Grey slide bar will light up * Click & slide your cursor to the lower right corner of text box. * Click the "I agree" box to confirm you read the text
CANCELLATION POLICY

* 48-72 hour cancellation notice is ideal
Client Signature

* By signing below, you acknowledge that you have read and understood the terms and conditions in this form
Client Name*

First Last
Date*

MonthDayYear
Date
Client Signature*
* MAKE SURE TO SUBMIT FORM *

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Parental Consent for a Minor

* ONLY complete on behalf of a minor under 18 years of age. Parent/ guardian must sign
Parent/ Guardian Name

First Last
Relationship to the Minor
(Parent/ Guardian, etc. )
Parent/ Guardian Signature
Should be Empty:

Electrology-Health History Form

Hair Removal Methods

SKIN/ HEALTH INFORMATION

Personal Health Information

Gender Affirming Care

Client Acknowledgement of Information

How to click "I agree" boxes

CANCELLATION POLICY

Client Signature

* MAKE SURE TO SUBMIT FORM *

Parental Consent for a Minor