Health History Assessment Page 2
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3Check the following, if you have ever had, or have been treated for the following conditions:
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Bleeding Problems/Hemophilia*
High Blood Pressure
Diabetes
Herpes (location) __________
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Circulatory Problem
Heart Disease
Cancer
Sexually Transmitted Diseases
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Breathing Problems
HIV Blood Test
Chemo/Radiation
Hepatitis (Type) __________
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Pacemaker*
Epilepsy
Tuberculosis
Other
Comments on above if checked: ____________________________________________________________________________
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Currently being treated by a physician or other healthcare provider: _________ Explain: _______________________________
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Current medications (oral, injection, topical – Rx & non-Rx): _____________________________________________________
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Past medications (oral, injection, topical – Rx & non-Rx): ________________________________________________________
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Do you have temp./perm. implants (i.e. IUD, dental, orthopedic): ______________ Do you wear contacts: ________________
Is your stress level average or high: _________________________________________________________________________
Frequency of gyn. examinations: ____________________________ Date of last exam: ________________________________
Are you presently pregnant or are attempting to become pregnant: _______________ Have menstrual cycle every________days
If post-menopausal, give date of last menses: _______ Was menstrual cycle regular: _______ Increase/decrease of hair: ______
Hysterectomy: ________ Date: ______________ Ovaries removed: ___________________ Increase/decrease of hair: _______
Estrogen/progesterone therapy: ____________ Dates/explain: ________________________ Increase/decrease of hair: _______
Ever taken birth control pills: _______________ Dates/explain: _______________________ Increase/decrease of hair: ______
Ever had an ovarian cyst or cystic ovaries: __________ Date/explain: ______________________________________________
Is thyroid function normal: ________________ Explain: ________________________________________________________
Changes in weight or voice: ________________ Explain: ________________________________________________________
Ever inform your physician/gyn. of your hair growth: ___________ Response: _______________________________________
Ever had a hormone test: _______________________ Date/results: ________________________________________________
I understand health history information is important to the electrologist in order to provide me with safe and effective
electrology treatments. I acknowledge all information given to me is accurate to the best of my knowledge, and I agree to
update my health history assessment whenever there are changes.
I understand a series of treatments is necessary to achieve permanent hair removal based on my previous temporary methods of
hair removal, the science of electrology, and my individual physiological factors.
I have been advised of the post–treatment healing process, the possible risks related to treatment and agree to follow all
aftercare instructions, and to notify the electrologist of any difficulty in healing.
I understand that photographs taken prior to treatment and during the process of my treatments will aid in providing feedback
on the treatment plan. I understand these photographs are for private educational use and will be used accordingly.
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Client’s Signature
Parent’s/Guardian’s Signature of Minor
Date
I acknowledge the following tissue alterations in areas to be treated: _______________________________________________
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Client’s Signature
Parent’s/Guardian’s Signature of Minor
Date
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