Electrolysis Client Questionnaire

Build a complete picture of each client before an electrolysis session, from health history and medication to sun exposure and hair-removal habits, plus the required acknowledgments. Everything signed and organized for aesthetic clinics.

Use this template

Full name

Nombre

Apellido

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone number

Date of birth

Have you had laser or electrolysis before?

Yes No Not sure

Please provide details

Which areas would you like treated with electrolysis?

Do you have any hormonal imbalances?

Yes No Not sure

Please provide details

When were you last exposed to the sun?

This week This month 1–3 months ago More than 3 months ago

Please provide details

Are you using retinol, hydrocortisone, Retin-A, bleaching cream, or other prescription topicals?

Yes No Not sure

Please provide details

Any cosmetic tattoos or permanent makeup in the treatment area?

Yes No Not sure

Have you taken antibiotics in the last 14 days?

Yes No Not sure

Please provide details

Are you taking prescription medication or dietary supplements?

Yes No Not sure

Please provide details

Do you wax, tweeze, shave, or use depilatories on the area? Note the method and how often.

Yes No Not sure

Please provide details

Are you pregnant or breastfeeding?

Yes No Not sure

Any Botox, fillers, resurfacing, or chemical peels in the past six weeks?

Yes No Not sure

Please provide details

History of cold sores (HSV)

Yes No Not sure

Any other medical condition, injury, or information we should know about?

Yes No Not sure

Please provide details

Treatment terms and conditions

I understand results are not guaranteed because complications, both known and unknown, can occur.