Rejuva Kare Trichology Clinic
This form is solely used to obtain the required information about the clients needs. This form is not intended to diagnose, prescribe, treat or cure any disease/ condition. All information is used to support all medical professionals, MD's, such as but not limited to Primary Care, Dermatology, or Endocrinology with the intent to collaborate in the health of the client's hair and scalp disorders.
Name
First Name
Last Name
Age
Gender
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
General Health & Medical History
Please answer all questions truthfully and to the best of your knowledge
Within the last year, have you been under the care of a dermatologist, primary care, or endocrinologist? If yes, what type of medical professional and why?
*
Yes
No
If yes, please specify:
Have you been diagnosed with any thyriod conditions (e.g., hypo or hyperthyroidism, Hashimoto's, Graves' disease?
*
Yes
No
If yes, what treatments or medications are you currently taking?
Have you recently experienced any significant weight changes? If yes, please describe.
*
Yes
No
If yes, please specify:
Have you been diagnosed with PCOS, indulin resistance, or other metabolic conditions?.
*
Yes
No
If yes, please specify:
Do you have a paternal ( parents or siblings) family history of hair loss or scalp conditions?
*
Yes
No
If yes, please specify if hair loss is siblings or on the mother or father side of the family.
Are you taking medications associated with hair loss, scalp condition, or hormonal imbalance? Please list all current medications:
*
Yes
No
If yes, please specify:
List any supplements, Chinese medicines, vitamins, diuretics, slimming pills, Accutane, etc, that you take regularly. Also, any nutritional deficiencies (iron, Vitamin D, B, etc.)
*
Do you smoke?
*
Yes
No
Do you exercise regularly?
*
Yes
No
Do you have metal implants, a pacemaker or body piercings?
*
Yes
No
How is your stress level?
*
Same
Improved
Worse
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?
*
Yes
No
Any changes in your diet or nutrition? If yes, please explain:
*
Yes
No
Rate your stress level on a scale of 1 to 5
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Your Skin
What are your specific concerns / challenges with your skin/hair?
*
Which of the following best describe your scalp? Please check all that apply:
*
Chronic Scalp Dryness
Oily
Yellowish Crust-Flaky
Normal
Sensitive/Irritation
Dandruff
Redness
Bumps
Ingrown Hair
Thinning
Breakage
Scalp infection
Other
Have you experienced any of the following conditions? Please check all that apply:
*
Heart Trouble
Hypertension (High Blood Pressuer)
Low Blood Pressuer
Thyroid Imbalance
Pituitary Imbalance
Blood Disorder
Seizure Disorder
Diabetes
Low Blood Sugar
Iron Deficiency ( Anemic )
Psoriasis
Eczema
Keloid
Steroids
Skin, Scalp Disorder
Frequency of shampooing, please include product names ?
*
Yes
No
If yes, Please explain:
Any changes in your diet or nutrition such as fasting, weight loss?
*
Yes
No
If yes, Please explain?
Has your hair shedding slowed down?
*
Yes
No
Have you seen any new hair growth?
*
Yes
No
Does your hair feel thicker?
*
Yes
No
Any recurrent attacks of patchy hair loss?
*
Yes
No
Female Clients Only
Are you taking oral contraception?
*
Yes
No
Are you pregnant?
*
Yes
No
Are you lactating?
*
Yes
No
Are you currently having or due for a menstrual cycle?
*
Yes
No
Male Clients Only
Have you had to take a PSA blood test for the screening of prostate cancer?
*
Yes
No
If yes, please specify:
Questions to discuss every visit
Have you started any new medications since your last visit?
Yes
No
If yes, please specify:
*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
*
Print
Submit
Submit
Should be Empty: