Client Health Questionnaire

CLIENT INTAKE FORM
First Name *
Last Name *
Preferred Name
Gender:*

MaleFemaleOther
Preferred Pronoun:
Address *
City, State*
Postal Code *
Birth Date *
Email*
Cell Phone Number *
Other Phone Number
Emergency Contact *
Phone Number *
Hormone Related Questions
Regular Menstrual Cycle?*

YesNoN/A
How often do you get your period (days)? (N/A if not applicable)*
Are you pregnant?*

YesNo
Please check all the apply:*

Fertility ChallengesHormone/Endocrine DisorderIrregular PeriodsAcnePCOSMenopauseNone of the above
General Health Questions
Please check all the apply:*

AcneCardiovascular diseasePituitary issuesKeloidsHaemophiliaPacemaker/DefibrillatorDiabetesHeart problemsLoss of Sensitivity (Neuropathy)High/low blood pressureMetal ImplantsThyroid problemsPhlebitis (Thrombophlebitis)Epilepsy/SeizuresSkin CancerAnemiaCancer/remissionThrombosisHIVHerpes I or IIHPV/wartsActive TBBruisingBack painNeck painAdrenal issuesHepatitisPancreatic issuesBreathing issuesHealing issuesNone of the above
Please list any health condition that was not mentioned above (N/A if not applicable):*
If you selected any of the above, please specify if the issue is ongoing or resolved (N/A if not applicable):*
Are you under a doctors care?*

YesNo
Recent Surgery?*

YesNo
Do you take medication?*

YesNo
If yes, specify what and what for (N/A if not applicable)*
Do you take supplements?*

YesNo
If yes, specify what and what for? (N/A if not applicable):*
Please select any that you are currently taking:*

HormonesAnti-InflammatoryAnticoagulantAspirinAntibioticsSteroidsAnti-histamineAccutane (past 6 mos)Contraceptive PillsDiureticContraceptive Implant (IUD)None of the above
Have you ever had any of the treatments below:*

Chemical peelingBotoxDermal fillersLaser resurfacingMechanical dermabrasionRejuvenation techniques (IPL)None of the above
Date of last treatment (N/A if not applicable):*
Previous Hair Removal Methods

To prepare for electrolysis, you should stop all temporary hair removal methods like shaving, waxing, and tweezing about a week before treatment (minimum 3 days). Remember, I need to be able to see and grip the hair with a pair of tweezers to treat the hair.
Please check all that apply:*

Wax / SugaringDepilatory CreamHome Light-Based EpilatorBleachingTweezersShavingScissors / Cutting / ClippingThreadingNone of the above
How often do you remove the hair (area you wish to have treated):*

DailyWeeklyMonthlyInfrequentlyNone of the above
Have you ever had electrolysis treatments?*

YesNo
If yes, on which part of the body? (N/A if not applicable)*
How many hours? (N/A if not applicable)*
Date of last session (N/A if not applicable):*
Have you ever had laser hair removal treatments?*

YesNo
If yes, on which part of the body? (N/A if not applicable)*
How many sessions / % removed? (N/A if not applicable)*
Date of last session (N/A if not applicable):*
Have you had a sudden growth of hair on areas previously treated with laser?*

YesNo
If yes, when did it start / where? (N/A if not applicable)*
Skin reactions to previous hair removal methods (select all that apply):*

RednessPigmentationPimplesCrusts/scabsIngrown hairBumpsNone of the above
Areas to be treated for permanent hair removal (select all that apply):*

HairlineChinEyebrowsNoseCheeks / SideburnsAbdomen / TummyUpper / Inner ThighsFeet / ToesUpper LipNeck / Nape of NeckHands / FingersEarsShoulders / Arms / UnderarmsBikini (Partial / Brazilian / Manscaping) No genitalsBack (Upper / Center / Lower)Chest / BreastsLeg / Lower LegButtocks
Client Acknowledgement
1. I understand I must pay $40 for missed or cancelled appointments with notice less than 24 hours.

2. If I am running late, I agree to call or text Delicate Touch Electrolysis. I understand that while every effort will be made to accommodate my full session, I am responsible for the full cost of the originally booked appointment.

3. I have given an accurate health history and agree to update infomation whenever there are changes.

4. I have been given an explanation of electrolysis and understand that a series of treatments is necessary to achieve permanant hair removal.

5. I understand that there will be a post-treatment healing process and there are possible risks related to treatment.

6. I acknowledge that the success of my treatment depends on my cooperation with the recommended schedule, my adherence to proper post-treatment care, and following the guidance provided by my electrologist. I take full responsibility for caring for the treated area as instructed.

7. I agree to follow all aftercare instructions and to notify the electrologist if I have questions, concerns, or difficulty in healing.

8. I have read and agree to follow the before care instructions, including stopping all temporary hair removal methods at least one week (minimum 3 days) prior to appointment, and will notify my electrologist with any concerns, questions, or updates to my general health history.

* A parent or legal guardian must accompany a person 18 years of age or younger to provide written consent at the time of service, which will be witnessed by the electrologist.
I authorize Delicate Touch Electrolysis to use photographs of the treatment area for documentation and marketing purposes, including social media.*

YesNo
Date*

MonthDayYear
Date
Please type your full name below as your signature. I understand that my typed name serves as a legally binding electronic signature and confirms my agreement to the terms outlined above.*
By submitting this form, the client confirms that the information provided is accurate and that their typed name constitutes a legally binding electronic signature under applicable law.
Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
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CLIENT INTAKE FORM

Hormone Related Questions

General Health Questions

Previous Hair Removal Methods

Client Acknowledgement