Formulaire Santé Étape 1 de 10 10% Identification SectionName* First Name Last Name Email* Address* Address City AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve-et-LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukon Province Postal Code Date of Birth YYYY slash MM slash DD Cell PhoneHome PhoneOffice Phone Care 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 shaving How often do you use the above methods? Has there been a sudden appearance of hair on the site (s) to be depilated? * Yes No If so, since when? Do you know the cause? Healthcare professional treatment sectionAre you currently being followed for a dermatological treatment?* Yes No If so, what are the reasons and who is your doctor?Are you currently being followed for homeopathic care?* Yes No If so, what are the reasons and who is your homeopath?Are you currently being followed for a chiropractic treatment?* Yes No If so, what are the reasons and who is your chiropractor?Are you currently being followed for a physiotherapeutic treatment?* Yes No If 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 No Please 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 No If so, what happened?Do you have light-triggered headaches?* Yes No Do you suffer from allergies? ** Yes No If 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 No If so, please enter the last treatment date YYYY slash MM slash DD Are you having or have you had Accutane treatment?* Yes No If so, please enter the last treatment date. YYYY slash MM slash DD Are you having or have you had chemical peeling?* Yes No If so, please enter the last treatment date. YYYY slash MM slash DD Are you having or have you had a benzoyl peroxide treatment?* Yes No If so, please enter the last treatment date. YYYY slash MM slash DD Are you having or have you had gold salts (myochrysine) treatment?* Yes No If so, please enter the last treatment date YYYY slash MM slash DD Are you having or have you had microdermabrasion?* Yes No If so, please enter the last treatment date. YYYY slash MM slash DD Lifestyle sectionDo you practise one or more sports?* Yes No If so, which ones and how often?Do you regularly expose yourself to the sun?* Yes No If so, how often? How do you consider your skin? Sensitive Regular Preventive sectionDo you suffer from a loss of sensitivity?* Yes No If so, where?Do you suffer from neuritis?* Yes No If so, where?Do you suffer from osteoarthritis?* Yes No If so, where?Do you have a bone fracture?** Yes No If so, where? Body areas to bypass sectionDo you suffer from impetigo?* Yes No Do you have one or more warts?* Yes No Do you suffer from moluscum contagiosum?* Yes No Do you suffer from intertrigo?* Yes No Do you suffer from tinea versicolor?* Yes No Do you suffer from sycosis?* Yes No Do you suffer from alopecia?* Yes No If 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 No Asthma* Yes No High blood pressure* Yes No Low blood pressure* Yes No Heavy legs* Yes No Cold hands and feet* Yes No Hernia* Yes No Nervousness / Anxiety* Yes No Depression* Yes No Epilepsy (Controlled)* Yes No Epilepsy (Uncontrolled)* Yes No Hyperthyroidism* Yes No Hypothyroidism* Yes No Adrenal disorders* Yes No Ovarian disorders* Yes No Tuberculosis* Yes No Diabetes (Controlled)* Yes No Diabetes (Uncontrolled)* Yes No Difficulty in healing properly* Yes No Female sectionIf you are male, please ignore this section. Are you pregnant? Yes No Are you trying to become pregnant? Yes No Do you have children? Yes No If so, how many? Do you have regular periods? Yes No Do you have a hormonal imbalance? Yes No Have you been on hormone therapy? Yes No If so, when? MM slash DD slash YYYY Have you ever had your testosterone level checked? Yes No Do you have a copper intrauterine device (IUD)? Yes No Are you postmenopausal? Yes No If yes since when? MM slash DD slash YYYY Are you hysterectomized? Yes No Do you suffer from hirsutism (hairs on male areas)? Yes No Last sectionPlease write here if you have any remarks, comments or special requests.How did you hear about us? Tout sélectionner Friend referral Internet Google Internet Facebook/Instagram Poster Journal advertisement Advertisement vehicle Through APESEQ Yellow Pages Other If you got to know us other than via the above methods, how did you get to know us? Δ La fondatrice de 5@7 Beauté Isabelle St-Laurent Propriétaire, EsthéticienneTechnicienne en photo épilationElectrolyste
