Digital Consultation Form

Digital Consultation Form

for scalp health and hair loss concerns
Name*

First NameLast Name
What is your gender?
Male, Female, (other: please provide additional info if needed)
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What is your preferred method of communication?*

emailtextboth
How did you hear about me?*
Google, Nextdoor, Yelp, Facebook, Instagram, Friend, Hair Stylist, Doctor, NHLMA, US Trichology Institute; American Hair Loss Council; please specify
Occupation
If yes, please share your profession and the physical environment you work in.
Personal History
Do you have any allergies to ingredients in skincare or haircare that you are aware of?*
Please share any and all concerns related to diagnosed allergies or potential sensitivities; past or present.
Are you allergic to shellfish?*

YesNo
General Health
Overall health
Have you ever had surgery with general anesthesia?*
Please list any details regarding previous surgeries with general anesthesia.
Have you had or been diagnosed with any of these health concerns? Please select all that apply.*

StrokeHypertension Coronary Artery DiseaseAnemiaDepression/Anxiety Mental Health IssuesThyroid DiseaseDiabetesOther Endocrine DisordersLiver DiseaseSkin DisorderCancerAuto Immune DisorderPCOSNoneOther
Are you currently undergoing treatment for anything listed above? Or have had in the past?
Regarding any of the health concerns listed above.
Physician's name
Date of last physical
Did you have any bloodwork done?*

YesNo
How long ago and what were the results? Can you please bring with or access your results when in person for your appointment?
Please indicate if this was ordered by a doctor or functional medicine practitioner.
Do you smoke, vape or drink alcohol?
Please be specific. How long have you smoked? How many drinks per day/per week?
In the past year, have you experienced any trauma or unusually high stress (a move, loss of a loved one, relationship stress, divorce, job loss or change, health condition or diagnosis?) If yes, please be specific.
What do you do to reduce stress? Pray, meditate, therapy/counseling, exercise, read, breathing exercises, journal, any hobbies?
Have you sought help from a medical professional (Family Doctor, OB/GYN, Endocrinologist, Dermatologist) for your scalp or hair loss concerns? If yes, what did they say? Did they do a biopsy, run blood work, use a derma scope, prescribe or suggest oral medications, topicals or supplements?
Please share what potential diagnosis or treatments that were suggested.
Do you exercise regularly?

YesNo
Medications
Please indicate if you are and of these types of medications and select all that apply.

Anti-coagulantsAnti-hypertensiveHormonesThyroidAspririnMulti-vitaminsRadiation TherapyChemotherapyNone
Please list all medications, including birth control/IUD OR supplements you are currently taking or used to take regularly? Have recently started OR stopped taking medications/supplements? Changed dosage?*
.
Females Only
Females Only: Please check all that apply

Perimenopause/MenopausePost MenopauseHysterectomyPregnantNursing
Males Only
Males Only: Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?

YesNo
Males Only: Do you currently have an enlarged prostate or prostate cancer?

YesNo
Nutrition
Are you currently on a specific or restricted diet or eating plan, including Ozempic, Semaglutide or Tirzepatide?
Intermittent fasting, Vegan, Vegetarian, Gluten Free, Dairy Free or any restrictions?
How many daily servings of protein?
If you know, please specify grams
How many daily servings of fruit?
Please list the quantity and type
How many daily servings of vegetables?
Please list the quantity and type
How many daily servings of carbohydrates?
How many daily servings of caffeine?
If liquid, how many cups and what source? Soda, tea, coffee, and energy drinks (chocolate is a sneaky source too).
Have you gained or lost a significant amount of weight recently?*

YesNo
How much weight have you lost, and how long of a process has this been?*
Please share any relevant info. Was it a program, a surgery, doctor recommended, coached by a nutritionist, or dietitian?
Hair & Scalp
Is your scalp: please select all that apply*

DryOilyDandruffNormalItchy/Redness
Do you pull your hair?*

YesNo
Do you have any bumps or raised areas?*

YesNo
Do you experience a "crawling" sensation? Burning? or Tingling? Select any that apply.

CrawlingBurningTinglingNot sureNo
Have you had any recurrent attacks of patchy hair loss?*

YesNo
Do you have hair shedding of different lengths?*

YesNoNot sure
Do you have any noticeable areas of hair loss?*

NoneFrontCrownTopAll over the scalp
Was the onset sudden or gradual?
What age were you when you first noticed?
Has it stabilized or gotten worse in the past 3-6 months?

StablizedWorsened
Do you notice a lot of hair in your brush or shower?

YesNo
How many times a week do you shampoo?*
What brand and type of shampoo & conditioner are you using?*
Please indicate if you do not use conditioner
Do you use dry shampoo or any aerosol spray product at your scalp/root area?

YesNo
Please list the product type, brand name, and how often you use it.
Do you use a hair dryer or hot tools on your hair?*

YesNo
What temperature/heat setting do you use when blow-drying, curling or flat ironing your hair?
Cool, Warm, Hot? If it has a temperature setting, please share how hot or what setting you use.
When your hair is wet, do you use a towel to rub it dry?*

YesNo
Are you experiencing hair loss on other parts of the body?*

YesNo
What area?
Has this happened more than once? And has it come back?
Do you color your hair?*

YesNo
How often do you color your hair?
Do you color your own hair or have it done professionally?
Have you ever had a reaction to hair color?

YesNo
Is your hair loss concern caused by any medical problems or medications that you are aware of?
Heredity
Does hair loss or thinning run in your family or does anyone else in your family have the same issue? Consider both sides*

YesNo
Hair Loss: Parents

BaldThinning HairNot BaldUnknown
Hair Loss: Grandparents

BaldThinning HairNot BaldUnknown
Hair Loss: Silblings

BaldThinning HairNot BaldUnknown
Hair Loss: Aunts or Uncles

BaldThinning HairNot BaldUnknown
What options have your researched for your hair loss, including over-the-counter and prescriptions? Please select all that apply.*

Growth FactorsLow-Level Laser Therapy LLLTLaserCapPlatelet-rich plasma PRPRogaine/Minoxidil 5%Finasteride/PropeciaMicroneedlingTransplantsHair Replacement/Wigs/ToppersSMP Scalp Micro-PigmentationXTCHLCCBosleyHair ClubHims/HersNutrafolKeraniqueViviscalNoneOther
Have you tried any of those you researched?
What other options have you researched for hair loss?*
How much does your hair loss bother you?

SlightlyModeratelyHighly
What are your goals and expectations around your hair loss?*

Prevent further lossGain back hair quicklyGradually gain back some hairOther
What are your goals and expectation regarding your hair loss?*
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?

YesNo
Please indicate where hair loss bothers you the most.*

No variation in hairstyleGoing outside on windy daysSocial lifeSeeing old friendsParticipating in sportsOverall apperanceConscious of appearance at workSeeing pictures/videosWearing hats when going outSwimming or getting caught in the rainOverall self-esteemMeeting new peoplePeople make commentsOther
Please share more about what bothers you, specifically related to your hair loss.*
Consent for treatment

I agree to be evaluated and I understand I will first undergo a comprehensive preliminary evaluation by Holly Strack, a certified Hair Loss Specialist, and Clinical Certified Trichologist. The first check-up includes digital and microscopic pictures taken and stored in a personal file for further evaluation, for which I give my consent. By agreeing to these terms, I further understand that results will vary depending on a large number of factors including but not limited to my responsibility to follow through regarding at-home care. I agree I will hold Holly Strack LLC harmless of any liability in conjunction with recommended treatments. Any recommendations and/or treatment plans discussed are not to be used in place of medical advice, and/or to be used to treat/prevent any medical illness or conditions. I understand that it is my responsibility to consult with a medical professional between current conditions/medications/supplements and those that are recommended before starting. By clicking the submit button below, I agree to these terms.
Should be Empty: