New Client Consultation Form

Virtual Consultation Form
Date *

Month Day Year
Gender *

Male Female
Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
E-mail *
DOB *

Month Day Year
Date
Age *
Occupation *
Some occupations expose people to toxic chemicals~graphic artists working with dyes or pigments, auto mechanics/auto body repair who work with paints or solvents, hair stylist, office workers who are exposed to toner from copiers, etc. Or have high stress level - lawyers, sales, police, students
Referred by:? *

Website / Online Search Yelp Facebook Radio Salon Other Client Referral
If Referral, please list name
If Other, please provide the source
Medical History
Allergies *
Are you allergic to shellfish? *

Yes No
General Health *
Previous Surgeries with General Anesthesia
Especially recent surgery as general anesthesia or the stress of the surgery may cause a shed. Important to know if a woman has had a hysterectomy which will cause some hormonal shift even if she is on hormone replacement therapy.
Do you have any of the following medical problems? *

Stroke Congestive Heart Failure Irregular Heart Beat Hypertension (High Blood Pressure) Coronary Artery Disease Anemia Depression Thyroid Disease Endocrine Disorders Diabetes Liver Disease Rosacea
Congestive heart failure, irregular heartbeat, coronary artery disease are all cardiac issues that may require permission from a cardiologist before treatment, especially if you are going to use a higher strength minoxidil. Minoxidil was originally used to lower blood pressure, and as a side effect was found to help hair growth. It is a linear does drug so the higher the strength the better it works.

Anemia and Thyroid disease (hypothyroid and hypothyroid) may cause hair loss.

Diabetes - diabetics usually take longer to heal and if not controlled, may also cause poor circulation.

Depression and liver disease affect general health and medications given to treat these conditions may cause hair loss.
Presently Undergoing Medical Treatment for
Stress *
Stress is a big factor in hair loss, especially for women and may cause telogen effluvium. This condition even with treatment may take up to 16 weeks to reverse.
Medications (Please list name and dosage)? *

Anti-coagulants Anti-hypertensive Hormones Thyroid Asprin Multivitamins Radiation Therapy Chemotherapy
Please list any other medication(s) you are are. *
Many medications may cause hair loss as a side effect. The most common are anti-coagulants such as heparin, warfarin (Coumadin), Antidepressants, hormones (birth control as well as HRT), some thyroid medications, and statins (cholesterol lowering drugs). CLIENT SHOULD NEVER STOP MEDICATIONS WITHOUT CONSULTING THEIR DOCTOR.
Females Only
Female issues? *

Yes No
Post Menopausal? *

Yes No
Are you planning to get pregnant in the next 6 months? *

Yes No
Do you take Contraceptive Pills? *

Yes No
If Yes, how long have you taken them?
Males Only
Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?

Yes No N/A
Do you have an enlarged prostate or prostate cancer? *

Yes No
Men who have enlarged prostates or are being checked (PSA) for enlarged prostate, need to let their doctor know they are taking an "anti-androgen (saw palmetto) (XTC Supplements) or "Propecia/Finasteride) as they may cause the PSA to have a lower value than it really is.

The doctor may suggest you discontinue taking the supplement for a week or two, prior to having this test performed; for a more accurate reading of their level.
Nutrition
Are you a vegetarian? *

Yes No
How many daily servings of protein do you get?
How many daily servings of fruit do you get?
How many daily servings of carbohydrates do you get?
How many daily servings of vegetables do you get?
How many daily servings of caffeine do you get?
Lost weight recently? *

Yes No
How much?
Diet is very important for healthy hair. Adequate protein intake is essential. How much a person needs is based on body weight at .8g per kilogram (2.2 lbs). The only contradiction on this is a person who needs to restrict protein intake such as someone with kidney disease.

Vegetarians who do not eat any kind of animal protein will have a difficult time with adequate protein as there are two types of protein - complete (animal based such as meat, fish, and poultry which includes dairy products and eggs) and incomplete (nuts, legumes, soy, etc)

Fruits and vegetables are important and people should eat a variety of colors for the best nutritional value. Caffeine (coffee, tea, colas, chocolate, energy drinks) interferes with how your body processes B vitamins so excessive use should be avoided.

Anyone who has lost a lot of weight in a short period of time (diet, gastric bypass or bariatric surgery) will lose hair.
Conditions of Hair and Scalp
Is your scalp? *

Dry Oily Normal Dandruff
Any redness or itchy scalp *

Yes No
Do you pull your hair *

Yes No
Any bumps or raised areas *

Yes No
Recurrent attacks of patchy loss *

Yes No
Hair of different lengths *

Yes No
Areas of hair loss

All over scalp Front Crown
Any loss of hair on body *

Yes No
What area?
At what age did you notice hair loss? *
Was loss sudden or gradual *

Sudden Gradual
Some of this information you will notice when you examine the scalp. Dandruff may be a sign of an allergic reaction or an excessively dry scalp.

Redness, bumps, raised areas or itching may be a sign of an infection (bacterial or fungal) as well as insect bites or more serious problems such as melanoma. Any raised rash, scaly areas (raised white scaly areas may be psoriasis) or open cuts/wounds should be referred to their physician or a dermatologist. Patchy areas on the scalp, eyebrow, facial hair (men), may be alopecia areata. This is usually a sudden hair loss that may progress to totalis (all the scalp hair) or universalis (all body hair). It may only be an allergic reaction but the cause is not really understood. Hair loss may be a symptom of a disease such as lupus and I usually recommend that people with alopecia areata see their doctor to rule out serious autoimmune disease.

Another cause of patchy loss would be scarring alopecia. This is usually seen as a red area that may have some drainage. When it heals, it is very smooth with no hair. A diagnosis of scaring alopecia is usually done by biopsy of the area by a dermatologist. There are no follicles in the scarred areas and regrowth is not possible. The hairs around these areas may be strengthened with treatment and may make these areas easier to hide with other hair.

There may also be chemicals (perms, strong chemicals) or physical scaring (heat, accident) where regrowth may not be possible.

Occasionally a person with Trichotillomania will come for treatment. These people pull out their hair, eyebrows, eyelashes and may benefit from counseling to find out the cause of this abusive type of behavior. If they continue to pull out their hair, the loss may become permanent.
Is your hair loss getting worse *

Yes No
How many hairs per day are you losing?
Some hair loss is normal. Normally approximately 10% of the hair is in the growth stage and a person may lost 50 to 100 hairs daily and still be considered normal. It is when people see hair all over their pillow, sink, and clothes that there is a real concern and they seek treatment. People like animals, do occasionally shed and is not cause for alarm as long as they are replacing those hairs which would be visible with the capilloscope.
What kind of shampoo do you use *
Shampoos without sodium laureth sulfate (SLS) or DEA are safer and healthier. SLS may cause irritation and DEA when it sits on the shelf in a cosmetic product may react with other ingredients to form a potent carcinogen called nitrosodiethanolamide (NDEA). These ingredients are added to shampoo because they emulsify the product and provide a rich lather that people think necessary to have "clean" hair.
How many times per week do you shampoo? *
Shampoos without sodium laureth sulfate (SLS) or DEA are safer and healthier. SLS may cause irritation and DEA when it sits on the shelf in a cosmetic product may react with other ingredients to form a potent carcinogen called nitrosodiethanolamide (NDEA). These ingredients are added to shampoo because they emulsify the product and provide a rich lather that people think necessary to have "clean" hair.
Do you use a hair dryer? *

Yes No
What temperature?

Hot Medium Cool
When hair is wet, do you use a towel to rub dry??

Yes No
Wet hair is more vulnerable and thin, weak hair may be damaged when vigorous rubbed.
Is your hair loss concern caused by and medical problems or medications that you are aware of?
If Yes List Condition
Heredity
Does hair loss run in your family?? *

Yes No
Parents *

Bald Thinning Hair Not Bald Unknown
If someone indicates they have no family history of hair loss, ask how far back they are going. Hair loss may skip a generation and is carried on several genes so it may randomly show up in family members or carry down from generation to generation on a regular basis.
What options have you researched for your hair loss (Including over the counter and prescriptions)? *

Transplants Scalp Treatments Hair Replacement or weaves Over the counter products Prescription products Avacor Minoxidil Clubs or Hair Loss Clinics
How much does your hair loss bother you? *

Slightly Moderately Highly
Did you tell anyone that you were coming here today?? *

Yes No
Would you like to consider using prescription topicals and pills if you could get better results. Keep in mind, prescription products in general increase the cost of the program?? *

Yes No
What are your goals and expectations? *

Prevent further loss Gain hair back quickly Gradually gain some hair back?
Knowing that treatment and/or surgical options may take 6 months or more to show success are you willing to wait that long? *

Yes No
Please indicate what bothers you the most about hair loss the most? *

No variation in hair style Going outside on windy days Social Life Seeing old friends Participating in sports Overall appearance Conscious of appearance at work Seeing pictures/videos Wearing hats when going out Swimming or getting caught in the rain Overall self-esteem Meeting new people People making comments
Consent for treatment
I am being evaluated at ________________________ and understand I will first undergo a comprehensive preliminary evaluation by one of our experienced thinning hair consultants. This evaluation will determine if I am a suitable candidate and I understand the cost of the initial evaluation is __________. All other follow up and scalp analysis, questionnaire, and scalp evaluation including standard photography (no face seen), and microscopic photography. Further evaluation will consist of monthly or quarterly digital and capilloscope pictures for which I give my consent for all of the above. I further understand that each person is different and like any treatment, results will vary depending on a large number of factors. I acknowledge that it is my responsibility to inform the company of any changes in my condition; no matter how slight.
Signature *
Date *

Month Day Year
Date
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Virtual Consultation Form

Medical History

Females Only

Males Only

Nutrition

Conditions of Hair and Scalp

Heredity

Consent for treatment