nurish.d - Hair Loss.Wellness.Aesthetics.
Intake Questionnaire
Full Name
*
First Name
Last Name
Phone Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
What is your Gender?
*
Male
Female
What is your age?
18-29
30-44
45+
What is your hair goal? Check all that apply
*
Length
Thickness
Stabilize loss
Stabilize loss & grow new hair
Does anyone in your family have hair loss?
*
Yes
No
How long have you been losing hair?
*
Less than 3 years
More than 3 years
Are you experiencing more hair shedding than usual?
*
Yes
No
Is your hair loss more prominent on the top of the scalp than the sides & back?
*
Yes
No
Are you thinning from your entire scalp?
*
Yes
No
Have you recently experienced a major stressful event (big move, a loss, job change, surgery)?
*
Yes
No
How often do you experience stress?
*
Never
Rarely
Somewhat often
Constantly
Are you pregnant or trying to conceive?
*
Yes
No
Have you had a baby in the last year or currently breastfeeding?
*
Yes
No
Are you experiencing any signs of menopause?
*
Yes
No
Do you follow any strict diet or eat vegan, vegetarian, keto?
*
Yes
No
How many servings of fruit & vegetables do you consume each day?
*
1-3
4-6
7-9
10+
Do you consume more than 5 alcoholic beverages per week?
*
Yes
No
Which of these are you experiencing regularly? Check all that apply
*
Constipation
Gas & bloating
Indigestion
None
Have you been diagnosed with or treated for cancer?
*
Yes
No
Do you take any medications for hormone replacement, cholesterol, blood thinners, blood pressure, anxiety, or acid reflux? Check all that apply.
*
Lipitor
Warfarin
Adderall
Wellbutrin
Xarelto
Synthroid
Accutane
Retinoids
Tamoxifen (estrogen inhibitors)
Prednisone
Nystatin, Fluconazole, Diflucan
Testosterone
Proton-Pump Inhibitor
None of the Above
Are you taking any vitamins or herbal supplements? Please list if so:
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