On line diagnosis for hair depilation
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* Required data
 
*Name: *Sirname: *Email: City:

Address: Postal code: Work Phone: Private phone:
Cell phone: Proffession:
Sex:  
Male Female
Age:
 
1. Hair type:
Thin
Average width
Thick
2. Hair colour:
Black
Brown
Blond
'White
Red
3. Upon exposure to direct sunlight for 1 hour without sunblock your skin will:
Always burn,no tan
Always burn,sometimes tans
Sometimes burns sometimes tans
Always gets a tan
Is dark and doesn't change
Is black
 
4. Which area of your body would you like to remove the hair from?
Face:
Upper lip
Cheek area
Jaw
Sideburns
Cheekbones
Forehead
Ears
Full face
Body:
Thighs
Armpitts
Calfs
String
Breast area
Forearm
Gluteal area
Sternum
Male chest
Neck back
Nipple area
Inner thighs
Legs
Bikini area
Abdomen centre
Arms
Shoulders
Upper abdomen
Male abdomen
Male back
Neck front
Waist
 
5. Are you pregnant?
Yes No
6. Cheloid scar formation history?
Yes No
7. Alcohol consumption?
Yes No
If yes elaborate please
 
8. When were you last exposed to sunbathing?
days
weeks
months
9. Do you ever use any sunblock protection and was it last used?
any tanning cream:
Tanning tablets:
Essential oils:
UV radiation:
10. Do you plan to sunbathe when in vacation?
Yes No
If yes when?
 
11. Diabetes mellitus history?
Yes No
12. Cushing or Addisons disease history?
Yes No
13. Skin allergy history?
Yes No
 
14. Photosensitivity history?
Yes No
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