Trichology Consultation Form
This form will allow us to better understand your situation and how we can help!!
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of Trichology (hair loss/ scalp) issue are you having?
hair
scalp
both
How long have you been having this issue?
Is the condition recurring or sporadic?
Recurring
Sporadic
Since many hair and scalp conditions can be genetic, to the best of your knowledge is the condition hereditary?
yes
no
I don't know
If yes, is it maternal side or paternal side?
Maternal
Paternal
Both
What is the relation to you?
In what ways are you and your relative's condition similar?
Have you been ill recently?
yes
no
If yes, did you have a fever?
yes
no
Have you undergone any recent surgeries?
yes
no
If yes, did you have general anesthesia?
yes
no
Are you currently experiencing any hormonal changes?
yes
no
(For women) Are you experiencing any hormaonal changes due to...
perimenopause
menopause
N/A
(For men) Have you experienced an increase or reduction in Testosterone?
Increase
Reduction
N/A
Have you had a annual physical recently?
yes
no
If yes, were all of your levels within normal range?
yes
no
If no, would you mind sharing what levels were not within healthy ranges?
Are you on any medication currently?
yes
no
If yes, how long are expected to continue this medication?
1-3 months
4-6 months
7-9 months
10-12 months
undetermined
If yes, was your current hair/ scalp condition explained to be a side effect of the medication?
yes
no
On a scale of 1-10, What would you say is your current level of stress
1-3 (low)
4-6 (moderate)
7-10 (high)
If you answered moderate to high, would you say that this is your normal working level?
yes
no
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?
yes
no
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?
yes
no
If yes, which type?
If yes, are you consistent in taking the recomended daily allowance?
yes
could be better
no
How often do you excercise, including taking 30-minute walk?
Regularly (3+ times/week)
When I can (less than twice/week)
Hardly ever
Never
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?
yes
no
N/A
Do you wear extension/weaves or braids regularly?
yes
no
N/A
Do you get relaxer services?
yes
no
N/A
If yes, who provides your relaxer services?
Me
Professional
other than a professional
How often do you touch up your relaxers?
Every 4-6 weeks
Every 8-10 weeks
3+ months
What is your desired outcome for your hair/scalp condition?
Submit
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