Trichology Consultation Form
This form will allow us to better understand your situation and how we can help!!
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What type of Trichology (hair loss/ scalp) issue are you having?
How long have you been having this issue?
Is the condition recurring or sporadic?
Since many hair and scalp conditions can be genetic, to the best of your knowledge is the condition hereditary?
I don't know
If yes, is it maternal side or paternal side?
What is the relation to you?
In what ways are you and your relative's condition similar?
Have you been ill recently?
If yes, did you have a fever?
Have you undergone any recent surgeries?
If yes, did you have general anesthesia?
Are you currently experiencing any hormonal changes?
(For women) Are you experiencing any hormaonal changes due to...
(For men) Have you experienced an increase or reduction in Testosterone?
Have you had a annual physical recently?
If yes, were all of your levels within normal range?
If no, would you mind sharing what levels were not within healthy ranges?
Are you on any medication currently?
If yes, how long are expected to continue this medication?
If yes, was your current hair/ scalp condition explained to be a side effect of the medication?
On a scale of 1-10, What would you say is your current level of stress
If you answered moderate to high, would you say that this is your normal working level?
If no, what would you say is causing this increased level of stress?
Do you feel that your hair/scalp condition gets worse during times of increased stress?
How is your diet?
Great (I eat a balanced diet and drink plenty of water)
Good (I try to eat healthy and drink water, but it could be better)
Bad (I do not eat as healthy as I could and rarely drink water)
Do you take vitamins/supplements?
If yes, which type?
If yes, are you consistent in taking the recomended daily allowance?
could be better
How often do you excercise, including taking 30-minute walk?
Regularly (3+ times/week)
When I can (less than twice/week)
How do you maintain your hair?
I do it myself mostly
I receive professional haircare services
I have someone other than a professional care for my hair
What is your usual haircare routine?
Do you wear ponytails or pull hair back often?
Do you wear extension/weaves or braids regularly?
Do you get relaxer services?
If yes, who provides your relaxer services?
other than a professional
How often do you touch up your relaxers?
Every 4-6 weeks
Every 8-10 weeks
What is your desired outcome for your hair/scalp condition?
Should be Empty: