Electrolysis Questionnaire
Please fill in the form below.
Full Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
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What part of your body are you wanting hair removed?
Have you had laser treatments on the specified area(s) in the past?
Yes
No
If yes, how were your results?
Ineffective
Moderately effective
Satisfactory
What method of hair removal are you currently using?
Tweezing
Waxing
Shaving
Depilatory creams
None
Have you been diagnosed with PCOS?
Yes
No
Are you under the care of an endocrinologist?
Yes
No
Are you undergoing Hormone Replacement Therapy?
Yes
No
Are you pregnant or trying to become pregnant?
No
Yes
Currently breastfeeding
Given birth within the last year
Do you have regular periods?
Yes
No
I don't have periods
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