Confidential Consultation Questionnaire

Confidential Consultation Questionnaire
Name
Date

Month Day Year
Date
Address
City
State
Zip Code
Home Phone
Work Phone
D.O.B
Age
E-mail
example@example.com
Referred By:

TV Ad Internet Social Media Radio Salon Other
History
Allergies
Are you allergic to shellfish?
General Health
Previous Surgery with General Anesthesia
Do you have any of the following medical problems? If so, please select

Stroke Congestive Heart Failure Irregular Heart Beat
Do you have any of the following medical problems? If so, please select

High Blood Pressure Coronary Artery Disease Anemia Depression Rosacea Thyroid Disease Endocrine Disease Diabetes Liver Disease Hypertensions
Presently Undergoing Medical Treatment for
Physician’s name
Date of Last Physical

Month Day Year
Date
Stress:

High Medium Low
Bloodwork: Have you had any of these tests done in the past year?

CBC w/DFF Ferritin/Iron Test Thyroid Panel Glucose Tolerance Hormone: HEA/Testosterone
Medications: Please list name of medication and dosage
Anti-Coagulants
Anti-Hypertension
Medications: Please list name of medication and dosage

Hormones Thyroid Aspirin Multivitamins Radiation Therapy Chemotherapy
Any other medications – Please List
Females Only - Hormonals Issues

Hormonals Issues: Yes No Post-Menopausal: Yes No
Females Only - Are you planning to get pregnant in the next 6 months?

Yes No
Are you currently pregnant or nursing?

Yes No
Do you take contraceptive pills?

Yes No
How long have you taken them?
We never give Minoxidil, Complete, AA, MGT, etc. or anything to pregnant, trying to get pregnant or nursing mothers other than shampoo and conditioner.
Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?

Yes No
Do you have an enlarged prostate, prostate cancer?

Yes No
Are you a vegetarian?

Yes No
How many daily servings of protein do you eat?
Fruit Vegetables Caffeine Carbohydraytes Protein
Low weight recently?

Yes No
How Much?
Conditions Hair and Scalp: Is your scalp:

Dry 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
Any loss of hair on your body:

Yes No
At what age did you notice hair loss?

Was loss sudden? or Gradual?
Is your hair loss concern caused by any medical problems or medications that you are aware of?
Heredity - Does Hair Loss run in your family?

Yes No
Hair Loss of Family Members (Check All That Apply)

Parents Grandparents Siblings Aunt Uncle NOT BALD UNKNOWN
What options have you researched for your loss (Including over the counter and prescriptions)? (Check All That Apply)

Over the counter products Prescription Products Avacor Minoxidil Other Clubs or Hair Loss Clinics Transplants Scalp Treatments Hair replacements or weaves
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 topical 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 back hair quickly Gradually gain back some hair Other
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
Trichology Hair Service Release Waiver Form
I (Name) authorize and release -
Angel's Eyes of Beauty from any pre-existing hair loss problems as it relates to my hair loss and scalp disorders consultation. I further release Angel's Eyes of Beauty from any lawsuits or claims that come as it relates to any services that I may receive. Angel's Eyes of Beauty practitioners have my permission to receive any information necessary from my previous stylist and medical professional either to myself or to whoever provides the free consultation service for purpose of clinical research.

I authorize information directly to 101 HLAWR of care listed above. I understand that hair growth is based on each individual’s hair loss and wellness needs. I give permission for documentation and photographs of any pre-existing problems to be taken and used by Angel's Eyes of Beauty. I agree that photographs and photographic copies of this statement shall be valid.
Client Signature

Clear
Date

Month Day Year
Date
Angel's Eyes of Beauty Practitioner
Date

Month Day Year
Date
Disclaimer: The purpose of this consultation is for Angel's Eyes of Beauty to gain knowledge by using our Medical Image and utilizing the Medical Questionnaire form. We may provide precautionary measures to possibly prevent the progression of hair loss and re-grow hair for the client. However, the Practitioners of Angel's Eyes of Beauty (hereafter referred to as Angel's Eyes of Beauty) assume absolutely no liabilities for any injuries resulting from the consultation or any other information provided by the Practitioner. Clients knowingly and willfully assume all such risks and responsibilities upon themselves and hold harmless Angel's Eyes of Beauty and any parties associated with Angel's Eyes of Beauty with respect to any and all hair care and health issues, whether arising from the negligence of Angel's Eyes of Beauty or otherwise.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Confidential Consultation Questionnaire

History

Medications: Please list name of medication and dosage

How many daily servings of protein do you eat?

Trichology Hair Service Release Waiver Form