Patient Medical & Hair History Form

General Patient Information
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?

YESNO
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.

Cancelof
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 ..?

GeneralPatchyIntermittent
Since onset of hair loss, has it gotten:

WorseBetterStayed the same
Is your hair

thinningsheddingboth
Does your scalp

itchflakeBurnfeel like pins and needles
Is your scalp reddened or inflamed?

YesNo
Hair Care and Styling
How often do you wash your hair?
What hair products do you use?
Do you use:

Hot rollersHair DyeCurling iron/flat ironRelaxer/keratinOther chemicalsOther
Do you regularly have any of the following hair styles?

PonytailsBraidsTwistsLocsWeaves/WigsHeadbands
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaPacemaker/DefibrillatorMetal in the body (Rods, scrap metal, etc.)Dental fillings, crowns, rodsChronic PainMotor Vehicle AccidentICD implant
Do you have metal or implants in the body?

Pacemaker/defibrillatorScrap metalRods, screwsNeurostimulatorsOther
Do you have any shunts in your body?

YesNo
Do you suffer from seizures or neurological disorders

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

High feverSevere infectionCovid19 (any variant)Flare of chronic illnessMajor surgeryTransplantOver or under active thyroidStart or stop beta blocker medicationSevere psychological stressLow iron in bloodWeight lossWeight gain
Do you have any of the following:

PsoriasisSeborrheic dermatitisCystic AcneEnlargement of clitorisExcess facial HairExcess body hairDischarge from breastsDeepening of voicePolycystic Ovary DiseaseHistory of Autoimmune disease (please list) ________________________________________________________________________________
Other illnesses:
What’s your blood type?
Are you on any kind of hormone therapy or ever received hormone therapy?

YesNo
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?

YesNo
Are you using a hormonal birth control?

YesNo
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

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

RegularIrregularLightModerateHeavy
Healthy & Unhealthy Habits
Exercise

Never1-2 days3-4 days5+ days
Have you drastically changed your diet recently

YesNo
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Water Intake

1-2 bottles/day3-4 bottles/day5+ bottles/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
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

YesNoOther
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.

YesNo
Should be Empty:

General Patient Information

Hair Care and Styling

Patient Medical History

Female Clients Only

Healthy & Unhealthy Habits