Jen H2Grow Questionaire

CONFIDENTIAL CONSULTATION QUESTIONNAIRE

Please answer question truthfully as possible. We are here to help you with restore your hair.
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
City
State
Zip
Phone Number
Format: (000) 000-0000.
DOB
Age
Occupation
E mail Address
example@example.com
Referred by:
Do you have any allergies?
If yes, please tell us your allergies
Are you allergic to shellfish?
Is your hair loss concern caused by any medical problems or medications that your are aware of?
General Health
Previous surgery with general anesthesia
Do you have any of the following issues?
If Yes, please tell us your following issues.
Presently undergoing treatment for:
Physician's name
Date of last physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Stress Level:
Do you Exercise?
Do you take any of the following
If yes, Please list name of medication and dosage.
Do you take supplements, and how often (example multivitamin, B12, Omega 3, Collagen, and more).
Females Only
Female issues
Post Menopusal
Are you planning to get pregnant in the next 6 months?
Are you currently pregnant or nursing?
How many pregnancies have you had?
Natural child birth or C section
Do you take Contraceptive Pills?
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?
Do you have an enlarged prostate, prostate cancer?
Nutrition
Are you a vegetarian?
Are you a vegan?
How many daily servings of protein?
How many daily servings of fruit?
How many servings of vegetables?
How many servings of caffeine?
How many servings of carbohydrates?
Lost weight recently?
How much?
Hair & Scalp Condition(s)
Is your scalp:
Do you notice any issues:
Do you pull your hair?
If yes, Where do you pull your hair?
Areas of hair loss
Do you relax your hair?
What age did you notice hair loss?
Is your hair loss getting worse
How many hairs lost per day?
What kind of shampoo do you use?
What kind of conditioner?
How many times per week do you shampoo?
What water temperature do you use?
When hair is wet, do you use a towel to rub dry?
HEREDITY
Does hair loss run in your family?
If yes, who has hair loss (bald) or thinning hair? ( For example: Parents, Grandparents, siblings, Aunt, Uncle)
What options have you researched for your hair loss (including over the counter prescriptions)?
How much does your hair loss bother you?
Did you tell anyone that you were coming here today?
What are your goals and expectations?
Knowing that treatment and/or surgical options may take 6 months or more to show success,

are you willing to wait that long? Yes
Knowing that treatment and/or surgical option may take 6 months or more to show success, are you willing to wait that long.
Please indicate where hair loss bothers you the most
I agree to being evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced consultant. All other checkups are included with the cost of the program, which include monthly and/or quarterly digital and microscopic pictures, for which I give my consent. I further understand results will vary depending on a large number of factors. I acknowledge that it is my responsibility to the company of any changes in my condition, no matter how slight.

I understand some general recommendations will be made based on the initial consultation
SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

CONFIDENTIAL CONSULTATION QUESTIONNAIRE

Females Only

Males Only

Nutrition