Hair & Scalp Clinic Dartford
Hair Loss and Scalp Problem Consultation Form
Select the reason for requesting a consultation:
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Hair Loss
Scalp Problem
Hair Damage
Hair Transplant Surgery
I am a returning client/patient
Other
Title:
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Name:
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First Name
Last Name
Date of Birth:
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-
Day
-
Month
Year
Date
Address
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Address Line 1
Address Line 2
City
County
Post Code
Sex:
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Male
Female
Prefer not to say
Other
Phone Number:
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-
Area Code
Phone Number
Email Address:
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example@example.com
GP Doctors details:
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Occupation:
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Does your job involve working with chemicals?
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Yes
No
Are you a past patient?
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Yes
No
ALLERGIES: Please list all allergies, including foods, fluids, medicines, cosmetics, if none, state N/A:
*
Upload images of your profile and hair or scalp problem:
*
Browse Files
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Choose a file
You can upload multiple files here
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of
HAIR: Please explain the problem with your hair:
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When did the hair problem start?
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Day
-
Month
Year
Date
What is the current condition of your hair?
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Hair loss - thinning
Patchy hair loss
Split ends
Damage due to heat
Breakage
Damage due to chemicals
Hair is dry
I don't have any hair
I pull out my own hair
Increased shedding of hair
Other
Hair type:
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Caucasian
Afro
Asian
Mixed / Other
How long is your hair?
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Please Select
Short
Medium
Long
I don't have any hair
Is there a history of hair loss in the family?
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No
Yes
SCALP: Please explain the problem with your scalp:
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When did the scalp problem start?
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Day
-
Month
Year
Date
What is the current condition of your scalp?
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Flaky
Pustules - Spots
Dandruff
Sore - Painful scalp
Itchy scalp
I pick, scratch rub my scalp
Dry
Normal
Oily
Other
Do you have any skin problems?
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No
Yes
Is there a history of skin problems in the family?
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No
Yes
Do you have any finger or toe nail problems?
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Yes
No
When did you last visit a doctor, dermatologist, trichologist, specialist about your hair or scalp problem?
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Day
-
Month
Year
Date
Who did you visit about your hair or scalp problem?
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Doctor
Dermatologist
N/A
Trichologist and Name
What diagnosis were you given?
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HEALTH: Do you have any problems with the following?
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Thyroid or Endocrine
Epilepsy
Bowel, Digestive
Asthma, Bronchitis, Chest problems
Diabetes: Type 1 or 2
HIV or Hepatitis
Cancer, Chemotherapy, Radiotherapy
Arthritis, Bone issues
Blood Pressure
Heart problem
Covid
Eyes: Glaucoma, other problems
N/A
Pacemaker
Giddiness
Blackouts
Liver
Kidney
Stroke
Other
HEALTH BLOOD: Do you have any problems with the following?
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Anaemia
Sickle cell anaemia
Thalassemia
N/A
Other
Are you currently taking any medications, drugs Internally or externally? If yes, please list them below, if not, state N/A.
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Please list any Vitamins / Minerals you are currently taking, if none, state N/A:
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HEALTH: Any major illnesses or accidents and if so what?
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No
Yes
SCALP SURGERY: Have you had any surgery for?
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Hair Transplant
Scalp or Brain Surgery
N/A
Other
List any surgeries for medical and/or cosmetic reasons, if none, state N/A:
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HEALTH MENTAL: Any problems with the following?
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Stress, Anxiety
Abuse
Trauma, Shock
N/A
Other
HEALTH DIET: Have you?
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Lost weight in the last year
Gained weight in the last year
Are you dieting
Vegetarian, vegan
Special health reason diet
N/A
Other
HEALTH: Do you smoke/vape?
*
Yes
No
HEALTH: Do you drink alcohol?
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Yes
No
HEALTH WOMEN: Do any of the following apply?
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Currently Pregnant
Breast feeding
Had a baby in the last 2 years
On a contraceptive pill
Had a Hysterectomy
On HRT
N/A
Other
Have you used the following on your hair before?
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Permanent hair colour
Keratin Treatment
Semi-permanent colours
Relaxer
Perms
Bleach
N/A
Other
When did you last colour, perm, bleach, keratin or relax your hair?
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Day
-
Month
Year
Date
What shampoo do you use?
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What conditioner do you use?
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Please list hair styling products you're currently using, if none, state N/A:
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Do you use hot irons?
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No
Yes, how often?
How did you hear about us?
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Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
Is there any other information you would like to add, if no, state N/A?
*
*
I understand you do not carry out court consultations and that your consultations are not suitable for any court cases. I confirm this consultation is not for court purposes past, present or future.
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I confirmed that all information indicated in this form is true and accurate.
Client Signature:
*
Date Signed:
*
-
Day
-
Month
Year
Date
Are you completing this form on behalf of someone else?
*
No
Yes, enter your name and relationship to the person
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