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Laser Hair Removal Qualifying Questionnaire

Client Information

Birthday
Month
Day
Year

Contraindications Screening

Please answer yes or no to the following:

Are you currently pregnant?
Yes
No
Has the area to be treated ever been sunburned?
Yes
No
Do you have any unidentified skin conditions in the treatment area?
Yes
No
Have you healed poorly after previous laser treatments?
Yes
No
N/A (never had laser treatment)
Are you prone to skin discoloration (hyperpigmentation/hypopigmentation)?
Yes
No
I don't know
Are you currently taking photosensitizing medication (e.g., Accutane)?
Yes
No
I don't know
If yes, have you discontinued Accutane for at least 6 months?
Yes
No
Are you currently using topical Retin-A?
Yes
No
If yes, has it been at least 2 weeks since last use?
Yes
No

Fitzpatrick Skin Typing Assessment

For each question, mark the box that best describes you.

What is your eye color?
What is your natural hair color?
What is the color of your skin in unexposed areas?
Do you have freckles on unexposed areas?
What happens when you stay in the sun for too long?
To what degree does your skin tan or darken after sun exposure?
Does your skin turn brown after several hours of sun exposure?
How does your face react to the sun?
When did you last expose your body to the sun, artificial tanning, or tanning cream?
How often is the requested treatment area(s) exposed to the sun?

Additional Medical & Lifestyle History

Have you used any hair removal methods in the past 6 weeks? (Shaving, waxing, electrolysis, tweezing, threading, bleaching)
Yes
No
If yes, which method(s):
Are you currently taking any medications (oral or topical)?
Yes
No
Do you have a history of poor healing or keloid scarring?
Yes
No
Do you have tattoos or permanent makeup in the treatment area?
Yes
No
Do you have any skin conditions (e.g., eczema, psoriasis, vitiligo, melasma) in the treatment area?
Yes
No
Have you had any recent skin cancers or suspicious lesions in the treatment area?
Yes
No
Have you used tanning lotions, self-tanners, or tanning beds in the past 2 weeks?
Yes
No
Are you currently breastfeeding?
Yes
No
Do you have any implanted medical devices (e.g., pacemaker, defibrillator)?
Yes
No
Do you have a history of cold sores or herpes simplex in the treatment area?
Yes
No

Client Goals & Expectations

Have you had laser hair removal before?
Yes
No
re you aware that multiple sessions are required and that results may vary?
Yes
No
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