Confidential Consultation Questionnaire

Confidential Consultation Questionnaire
Name
Date

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

TV AdInternetSocial MediaRadioSalonOther
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

StrokeCongestive Heart FailureIrregular Heart Beat
Do you have any of the following medical problems? If so, please select

High Blood PressureCoronary Artery DiseaseAnemiaDepressionRosaceaThyroid DiseaseEndocrine DiseaseDiabetesLiver DiseaseHypertensions
Presently Undergoing Medical Treatment for
Physician’s name
Date of Last Physical

MonthDayYear
Date
Stress:

HighMediumLow
Bloodwork: Have you had any of these tests done in the past year?

CBC w/DFFFerritin/Iron TestThyroid PanelGlucose ToleranceHormone: HEA/Testosterone
Medications: Please list name of medication and dosage
Anti-Coagulants
Anti-Hypertension
Medications: Please list name of medication and dosage

HormonesThyroidAspirinMultivitaminsRadiation TherapyChemotherapy
Any other medications – Please List
Females Only - Hormonals Issues

Hormonals Issues: YesNoPost-Menopausal: YesNo
Females Only - Are you planning to get pregnant in the next 6 months?

YesNo
Are you currently pregnant or nursing?

YesNo
Do you take contraceptive pills?

YesNo
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?

YesNo
Do you have an enlarged prostate, prostate cancer?

YesNo
Are you a vegetarian?

YesNo
How many daily servings of protein do you eat?
FruitVegetablesCaffeineCarbohydraytesProtein
Low weight recently?

YesNo
How Much?
Conditions Hair and Scalp: Is your scalp:

DryNormalDandruff
Any redness or itchy scalp:

YesNoDo you pull your hair? YesNo
Any bumps or raised areas?

YesNo
Recurrent attacks of patchy loss:

YesNo
Any loss of hair on your body:

YesNo
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?

YesNo
Hair Loss of Family Members (Check All That Apply)

ParentsGrandparentsSiblingsAuntUncleNOT BALDUNKNOWN
What options have you researched for your loss (Including over the counter and prescriptions)? (Check All That Apply)

Over the counter productsPrescription ProductsAvacorMinoxidilOtherClubs or Hair Loss ClinicsTransplantsScalp TreatmentsHair replacements or weaves
How much does your hair loss bother you?

SlightlyModeratelyHighly
Did you tell anyone that you were coming here today?

YesNo
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?

YesNo
What are your goals and expectations?

Prevent further lossGain back hair quicklyGradually gain back some hairOther
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?

YesNo
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

MonthDayYear
Date
Angel's Eyes of Beauty Practitioner
Date

MonthDayYear
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:

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