IMKELLEY TricHolistic Intake form

Holistic Hair Treatment Profile
Date*

MonthDayYear
Full Name*

First NameMiddle NameLast Name
Primary Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
African AmericanNative AmericanMediterraneanHispanicCaucasianNorthern EuropeanAsianOther
E-mail*
Best way to contact?*
Primary Physician*
Name
Height
Weight
# of children
Pets
How did you find out about IMKELLEY'?*
No-I decide on my ownYes-spouse/partnerYes-family memberYes-financial decision-maker (other)Not sure yet
What do you hope to achieve in your visit And through your hair/journey?*
How urgent does this feel right now?*
This helps us plan your next steps and timeline
Less sheddingMore thickness/densityScalp comfort ( itch/burn/flaking)Hairline/edgesCrown/part wideningOverall hair healthNot sure yet
If we recommend a personalized in clinic program, the questions below help us plan options that fit you. (this helps us recommend options that match your goals and comfort level)
SingleMarriedDivorce
I twirl/twist/pull my hair/eyebrowsI have hair different lengthsI have hair thinning at my templeI am thinning on the top of my headMy pony tail is getting smaller/shorterI wear extensions/weaves/hair piecesI have sudden hair lossOther
Dry/ItchyOilyDandruffCrawling/Burning sensationReddening/PainOther
My reason for coming today*
Do you need someone other than yourself to make a financial decision to begin your TricHolistic Program? If so, we ask they are present during your appointment.
If yes, I can share a simple summary after your consult so you can make a decision together
$2000-$4,000$4,000-$6,000$6,000-$8,000
In FullCare CreditCherry CreditHSA/FSA3 Monthly Payments
Client Narrative

Share anything you feel is important about your health, scalp, hair history, and your goals for this journey. The more context you share, the more personalized your recommendations can be.”
Did something trigger your change in health?*
What makes you feel better?*
What makes you feel worse?*
Have you had any medical diagnosis:
Current Habits

Check all the factors that apply to your current lifestyle and eating habits:
Fast eaterStruggle with eatingLove to cookNegative relationship with foodLove to eat"Eat because I have to" issuesErratic eating patternsEmotional eaterEat too much/overeatEat fast food frequentlyLate night eatingLive or often eats aloneConfused about food/nutritionTime constraintsFamily members have different tastesDislike "healthy food"Rely on convenience itemsPoor snack choicesDo not plan mealsTravel frequentlyVeganVegetarianMacrobioticHigh ProteinOrganicLocalRaw FoodsStandard American Diet (USDA)Gluten-FreeGluten/Casein Free
Please note any additional comments about your nutrition/eating habits:*
Physical Activity
Do you engage in moderate cardiovascular physical activity for a minimum duration of 20 minutes at least 3 days a week? For example: brisk walking, jogging, cardio exercise classes*

Please indicate the type of exercise you are currently engaging in.*

Rows	Type/Intensity (low/mod/high)	# Day Per Week	Duration (mins)
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports or Leisure
Other

Note any problems that limit your physical activity:
Daily Stressors

Rate on a scale of 1 (low) to 10 (high)

Work*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Family*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Relationships*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Finances*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Health*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Education*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Physical Activity*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Career Choice*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Other
Lifestyle Information
Is there any unusual excess stress in your life?*
Please explain:*
Do you easily handle stress?*
How do you handle stress? Please explain:*
Do you wake up during the night?*
If yes, how many times?
How would you rate the overall quality of your sleep? (0-low, 5-high)*
How many hours of sleep do you get a night?*

In order to improve your health, how willing are you to:(Rate on scale of 5-very willing to 1-not willing)

Rows	5	4	3	2	1
Come off dairy, cakes, cookies, ice cream, breads ett
Modify your lifestyle (work demands, sleep habits, exercise)
Practice a relaxation technique
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress

What do you think would make the most difference in your overall health?*
What physical symptoms are you currently experiencing*
ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPAA PRIVACY ACT - CONFIDENTIAL / HIPAA APPROVED FORM
HIPAA

NOTICE OF PRIVACY PRACTICES
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Signature

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Health & Service Release Statement-IMKELLEY Trichology Center

I understand that services provided by IMKELLEY Trichology Center are non-medical trichology and scalp wellness services. These services are educational, cosmetic, and supportive in nature and are not intended to diagnose, treat, cure, or prevent any disease or medical condition.

I acknowledge that recommendations related to scalp care, nutrition, supplements, lifestyle, and hair restoration protocols are provided for educational and wellness support purposes only. I understand that results may vary and that no guarantees of outcome have been made.

I agree that I am responsible for consulting with my physician or qualified healthcare provider regarding any medical concerns, diagnoses, medications, or treatment decisions.

I accept responsibility for my participation in services and agree to report any medical conditions, sensitivities, or changes in health status that may affect my services.

By signing below, I confirm that I have read and understand this Health & Service Release Statement.
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What age did you notice the hair loss?*
Is your hair loss getting worse?*
What is your current brand and shampoo and conditioner?
How often do you shampoo?*
HotMediumCoolTowel Dry
Is your color permanent or rinse?*
Has your hair been over-processed to your knowledge?
NeglectUnprofessional careColorChemicalsUnknown
Is your hair care professional or at home?
Professional stylist's name and phone number
Parents (mom and dad)Maternal grandparentsPaternal grandparentsSiblingsAuntsUncles
TransplantsPRPFDA Approved laser therapyStem CellFinesterideVisvicalMonoxidilRogaineHair ReplacementOther
DepressionHormonal ImbalanceThyroid/Thyroid panelCongestive Heart FailureHypertensionDiabetes/Glucose TolerantAnti-depressantsAnti-coagulantsRadiationHIVCholesterolAllergiesAllergies to shellfishSleep disordersLost/gained weightCovidAuto immune disorders noAre there any medical conditions not listed that I should be made aware ofAny recent surgeries in the past 6montheOther
Last x-ray
Pre-MenopauseMenopausePlanning to get pregnantCurrently nursingOral contraceptives
PSA screeningEnlarged prostateProstate cancer
I am presently undergoing treatment for:
Please list any additional information you feel we need to know about your hair
Primary Care name/number*
Endocrinologist name/number
Dermatologist name/number
CCCA ( Central Centrifugal Cicatricia Alopecia)Cicatricial Alopecia (Scarring Alopecia)Alopecia Areata (Patchy Hair Loss)Telogen Effluvium ( Excessive shedding)Anagen Effluvium ( Excessive growing hairs only)Loose Anagen Syndrome ( Shedding new hairs)Diffused Alopecia ( All over shedding)Alopecia Totalis ( Total hair loss to the scalp)Alopecia Universalis ( Total hair loss of the body)Other
Please list what you had for breakfast, lunch, dinner and snacks as well as liquids, yesterday
COVID 19 Active Screening Questionnaire
CoughSore throatShortness of breathMuscle achesExtreme feverNone
yesno
IMKELLEY Hair Restoration LLC does recognize the suggested CDC, WHO, and State regulations can have adverse affects on the health of some individuals. With this in mind, if you currently follow Nature's L.A.W.S (take care of your health, eat right, exercise, rest, water, prayer, meditation, etc), we applaud you and encourage you to continuing doing so to boost and maintain a healthy state of mind and body.
Model Release
Media, Image & Educational Use Consent IMKELLEY Trichology Center

I grant permission to IMKELLEY Hair Restoration, LLC / IMKELLEY Trichology Center to capture and use scalp and hair images, photographs, video, and consultation visuals for documentation, treatment tracking, education, and professional review purposes.

With my separate consent (if selected elsewhere in this form), selected images may also be used for marketing or educational materials, including website content, presentations, brochures, and professional training. Identifying personal information will not be included unless I provide explicit written permission.

I understand that images used for education or marketing will be anonymized whenever reasonably possible.

I acknowledge that I am 18 years of age or older and legally able to provide this consent. I confirm that I have read and understand this release before signing.
I consent to the audio recording of my consultation for documentation, treatment planning.
I understand that de-identified consultation insights, clinical observations, and non-identifying hair or scalp images from my session may be used when appropriate for professional education, training, and case review purposes. My name, face, and personal identifying information will not be shared.
All educational use is de-identified and confidential.
I consent to the use of hair and scalp images only for marketing and educational promotion.
HIPAA Privacy Notice, Client Information Protection & Scope of Services — IMKELLEY Trichology Center*
Scope of Services & Client Consent

Your privacy is important to us. We respect and protect the confidentiality of your personal health and wellness information in accordance with applicable privacy standards, including HIPAA (Health Insurance Portability and Accountability Act) principles for handling sensitive information.

Information you provide through this intake form, consultation, scalp imaging, laboratory reviews, and follow-up communications is used for purposes related to your trichology consultation and scalp wellness services, including assessment, treatment planning, progress tracking, and client communication.

De-identified clinical insights and non-identifying hair or scalp images may also be used for professional education, training, and case review purposes.

Your information is not sold or shared for unrelated marketing purposes. Information may be shared with other professionals or laboratories only when necessary for care coordination and only with your authorization or request.

IMKELLEY Trichology Center provides non-medical trichology and scalp wellness services. These services are educational, supportive, and cosmetic in nature and are not a substitute for medical diagnosis or medical treatment. We do not diagnose disease, prescribe medication, or replace care provided by a licensed physician. If medical concerns are suspected, referral to a qualified healthcare provider may be recommended. Any nutrition, supplement, lifestyle, or scalp care recommendations are provided for educational and supportive purposes.

Scalp photographs, microscope images, and progress images may be collected for documentation, assessment accuracy, and treatment tracking. These images are considered part of your confidential client record. De-identified images may be used for professional education and case review as outlined in this intake. Marketing or promotional use requires separate, optional authorization.

By signing below, you acknowledge that you have read and understand this privacy notice, information protection policy, and scope of services disclosure, and you consent to the collection and use of your information for consultation and service planning purposes.

This consent applies to trichology and scalp wellness services and does not replace or substitute medical evaluation or treatment.
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Holistic Hair Treatment Profile

Client Narrative

Current Habits

Physical Activity

Daily Stressors

Lifestyle Information

ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPAA PRIVACY ACT - CONFIDENTIAL / HIPAA APPROVED FORM

HIPAA

COVID 19 Active Screening Questionnaire

Model Release