Trichology Questionnaire

TRICHOLOGY QUESTIONNAIRE FORM
First Name
Last Name
Date

MonthDayYear
Date
Date of Birth
Occupation
E mail
example@example.com
Referred By
example@example.com
Other
Salon
Facebook
Instagram
Address
City
State
Zip
Home
Work
Cell
ALLERGIES
Are you allergic to shell fish?
Previous Surgery with Anesthesia?
Do you have any of the following?
High Blood Pressure
Skin disorders
Thyroid Disease
Presently undergoing treatment?
Supplements: Please list by name
Medications: Please list name of medications
Medications
Thyroid
Hormones
Chemotherapy
Post Menopausal.

YesNo
Are you currently pregnant or nursing?
Yes
no
Do you take Birth Control.

YesNo
Are you a vegetarian

YesNoOther
Are you experiencing hair thinning,hair loss, dry scalp or any other scalp issue

. NoYesOther
How long have you been experiencing these conditions

I month-1yr1-3yrs3-5yrs5-10yrsOver 10yrs
Have you ever visited a Dermatologist?

YesNo
List areas of hair loss,Hair breakage

CrownTemplesOther
How many hairs have you lost per day?
Does hair loss run in the family?
What hair loss products have you tried
Is your Hairloss getting worse

YesNoOrher
Have you used Minoxidil?
Have you used prescriptions for hair loss?
Is your scalp

DryOilyNormalOther
Have you been diagnosed with any scalp issues
Have you ever been diagnosed with any of the below conditions
Does your scalp itch

YesNoOfher
Do you have raised bumps

. YesNo
Do you have recurring patchy hair loss

YesNoOther
Do you have different lengths?
Do you have any hair loss on any other areas of the body?

YesNoOther
At what age did you notice hair loss
Was you hair loss

SuddenGradual
When wearing extensions are they usually very tight and you have to wait a few days for them to loosen up?
Are you under a physicians care?

YesNoOther
Have you taken hair vitamins?
How much water do you drink?
How much sleep do you get?
What kind of shampoo do you use?
What kind of conditioner do you use
Do you use a hair dryer. If so what do you have it on

Hotmed. Low
Do you wear hair color?
Have you ever had a reaction to hair color

YesNoOrher
Do you color your hair at home or Salon?
Do you relax or Perm your hair?
How often do you apply heat to your hair?
Have you had a transplant
When was your last Trim/ Cut
How often do you hot curl your hair
How would you rate your hairs condition
How often do you visit the hair salon?
Treatments may take 6 months or more to show success, are you willing to wait that long?
Yes
No
Please indicate where hair loss bothers you most?

SwimmingGoing outside on a windy daySocial lifeOverall appearanceParticipating in sportsSeeing old friendsseeing picturesMeeting new peopleComments from peopleAppearance at work
Pls upload photos of front ,sides,and,back
File Upload

Cancelof
I agree to being evaluated and I understand I will first undergo a preliminary evaluation by an experienced consultant. Which includes digital and microscopic pictures, for which I give my consent. I further understand that results will vary depending on a large number of factors.I acknowledge that it is my responsibility to share any changes in my condition no matter how slight.
I understand some general recommendations will be made based on the initial consultation.
Signature

Clear
Date

MonthDayYear
Date
Please verify that you are human*
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