Patient Medical & Hair History Form

Patient Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age

Patient Birth Date

MonthDayYear

Patient Height (inches)

Patient Weight (lbs)

Patient E-Mail

example@example.com

Do you agree to receive emails from Healing Strands LLC?

Who were you referred by?:

Reason for seeing the trichologist:

Do you have a primary care provider?

Have you had any blood work done in the last year (12 months)?

Have pictures of your scalp/area of loss? Please upload them to better help the Trichologist analyze your condition. Be sure your uploaded images are clear with good lighting.

Hair Loss and Scalp Health

When did you hair loss start (approximately)?

Where are you experiencing hair loss?

Does hair loss run in your family?

If so, who has it?

Is your hair loss ..?

Since onset of hair loss, has it gotten:

Is your hair

Does your scalp

Is your scalp reddened or inflamed?

Hair Care and Styling

How often do you wash your hair?

What hair products do you use?

Do you use:

Do you regularly have any of the following hair styles?

Please list any drug allergies

Have you ever had (Please check all that apply)

Do you have metal or implants in the body?

Do you suffer from slow wound healing?

Do you bruise easily?

Do you tug, fidget with, or pull at your hair? (If you find yourself realizing that your hands wander over your scalp often unknowingly, select "Yes")

Do you have any shunts in your body?

Do you suffer from seizures or neurological disorders

In the last 3-12 months, have you experienced?

Do you have any of the following:

Other illnesses:

What’s your blood type?

Are you on any kind of hormone therapy or ever received hormone therapy?

If "yes", how long?

Please list any Operations and Dates of Each

Please list your Current Medications

Have you already seen a professional for treatment? If yes, please explain?

What treatments are you currently using for hair loss (medications, injections, Rogaine, vitamins, shampoos, etc.?)

Female Clients Only

Have you recently had a child in the last 3-12 months?

Are you using a hormonal birth control?

If "yes", what type and for how long?

Or if you have stopped taking it, when did you stop?

Do you have a history of

Other

If applicable, are your menstrual periods (check all that apply):

Exercise

Have you drastically changed your diet recently

Eating following a diet

Alcohol Consumption

Caffeine Consumption

Water Intake

Do you smoke?

Include other comments regarding your Medical History

IF YOU HAVE HAD ANY RECENT BLOOD WORK DONE, PLEASE HAVE THEM READY FOR YOUR CONSULTATION TO DISCUSS. THIS IS IMPORTANT SO THAT WE CAN DISCUSS ANY DEFICIENCIES WITHIN THE BODY. IF YOU HAVE ACCESS TO A PATIENT PORTAL THROUGH YOUR CARE PROVIDER WHERE YOUR LABS WERE DONE, YOU CAN JUST PULL THEM UP ON YOUR PHONE OR SCREENSHOT THEM FOR THE CONSULTATION. IF YOU WOULD LIKE TO SEND THEM VIA EMAIL, YOU CAN SEND THEM TO INFO@HEALINGSTRANDSHAIR.COM AND BE SURE TO CROP OUT ANY PATIENT IDENTIFIERS (HOSPITAL NAME, YOUR NAME, DATE OF BIRTH, MEDICAL RECORD NUMBER, SOCIAL SECCURITY, ETC.) SINCE EMAIL IS SUBJECT TO SPAM AND PHISHING.

Your progress will be photographed (no face shown unless given permission). Do you consent to the use of hair progress photos (no identifying markers) for the use of business promotion and educational purposes (such as case studies) on flyers, social media, and/or email marketing

Other

Do you consent to the use of photos and data with non-identifying markers to be used in case studies among other trichologists in which Brittney networks to help with further education and the advancement of this practice.

General Patient Information

Hair Care and Styling

Patient Medical History

Female Clients Only

Healthy & Unhealthy Habits