Identification and health questionnaire for Épilation Laser Canada.Step 1 of 1010%Identification SectionName* First Name Last Name Email* Address* Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Date of Birth YYYY slash MM slash DD Cell Phone*Home PhoneOffice PhoneCare request sectionWhich body area(s) do you wish to treat?*Which hair removal method(s) have you used in the last 6 weeks? Shaving Tweezer Electrolysis Wax Depilatory cream (Neet) Sugar Discolouration Laser Thread Electric shavingHow often do you use the above methods?Has there been a sudden appearance of hair on the site (s) to be depilated? * Yes NoIf so, since when? Do you know the cause?Healthcare professional treatment sectionAre you currently being followed for a dermatological treatment?* Yes NoIf so, what are the reasons and who is your doctor?Are you currently being followed for homeopathic care?* Yes NoIf so, what are the reasons and who is your homeopath?Are you currently being followed for a chiropractic treatment?* Yes NoIf so, what are the reasons and who is your chiropractor?Are you currently being followed for a physiotherapeutic treatment?* Yes NoIf so, what are the reasons and who is your physiotherapist?Medication and health sectionPlease list the medications you are taking.Do you have to take any medication before treatment (e.g. Valtrex) against oral or genital herpes?* Yes NoPlease list the natural products you are taking.Please list any creams and ointments that you apply to the skin.Were you recently involved in an accident?* Yes NoIf so, what happened?Do you have light-triggered headaches?* Yes NoDo you suffer from allergies? ** Yes NoIf so, which ones?Please indicate all health conditions that apply to you* Hepatitis B Hepatitis C HIV Seropositivity Existence or presumption of tumour Existence or danger of thrombosis Cardiac impella Pacemaker Heart problems or stroke – more than 6 months ago Heart problems or stroke – less than 6 months ago Pregnancy Chemotherapy or radiotherapy Inflammatory condition (pain) Blood circulation disorders Difficulty coagulating or other Medication Varicose veins Haemophiliac Metal inclusion I have none of these conditions*We do not perform photoepilation on someone who exhibits any of the problematic health conditions listed above.History of past medical treatments sectionAre you having or have you had a vitamin A acid (retinoic acid) treatment?* Yes NoIf so, please enter the last treatment date YYYY slash MM slash DD Are you having or have you had Accutane treatment?* Yes NoIf so, please enter the last treatment date. YYYY slash MM slash DD Are you having or have you had chemical peeling?* Yes NoIf so, please enter the last treatment date. YYYY slash MM slash DD Are you having or have you had a benzoyl peroxide treatment?* Yes NoIf so, please enter the last treatment date. YYYY slash MM slash DD Are you having or have you had gold salts (myochrysine) treatment?* Yes NoIf so, please enter the last treatment date YYYY slash MM slash DD Are you having or have you had microdermabrasion?* Yes NoIf so, please enter the last treatment date. YYYY slash MM slash DD Lifestyle sectionDo you practise one or more sports?* Yes NoIf so, which ones and how often?Do you regularly expose yourself to the sun?* Yes NoIf so, how often?How do you consider your skin? Sensitive RegularPreventive sectionDo you suffer from a loss of sensitivity?* Yes NoIf so, where?Do you suffer from neuritis?* Yes NoIf so, where?Do you suffer from osteoarthritis?* Yes NoIf so, where?Do you have a bone fracture?** Yes NoIf so, where?Body areas to bypass sectionDo you suffer from impetigo?* Yes NoDo you have one or more warts?* Yes NoDo you suffer from moluscum contagiosum?* Yes NoDo you suffer from intertrigo?* Yes NoDo you suffer from tinea versicolor?* Yes NoDo you suffer from sycosis?* Yes NoDo you suffer from alopecia?* Yes NoIf you suffer from another form of dermatosis, please let us know:Precautions to takeIn order to take the necessary precautions during treatment, please indicate which health concerns apply to you.Vitiligo* Yes NoAsthma* Yes NoHigh blood pressure* Yes NoLow blood pressure* Yes NoHeavy legs* Yes NoCold hands and feet* Yes NoHernia* Yes NoNervousness / Anxiety* Yes NoDepression* Yes NoEpilepsy (Controlled)* Yes NoEpilepsy (Uncontrolled)* Yes NoHyperthyroidism* Yes NoHypothyroidism* Yes NoAdrenal disorders* Yes NoOvarian disorders* Yes NoTuberculosis* Yes NoDiabetes (Controlled)* Yes NoDiabetes (Uncontrolled)* Yes NoDifficulty in healing properly* Yes NoFemale sectionIf you are male, please ignore this section.Are you pregnant? Yes NoAre you trying to become pregnant? Yes NoDo you have children? Yes NoIf so, how many?Do you have regular periods? Yes NoDo you have a hormonal imbalance? Yes NoHave you been on hormone therapy? Yes NoIf so, when? MM slash DD slash YYYY Have you ever had your testosterone level checked? Yes NoDo you have a copper intrauterine device (IUD)? Yes NoAre you postmenopausal? Yes NoIf yes since when? MM slash DD slash YYYY Are you hysterectomized? Yes NoDo you suffer from hirsutism (hairs on male areas)? Yes NoLast sectionPlease write here if you have any remarks, comments or special requests.How did you hear about us? Select All Friend referral Internet Google Internet Facebook/Instagram Poster Journal advertisement Advertisement vehicle Through APESEQ Yellow Pages OtherIf you got to know us other than via the above methods, how did you get to know us?
