Hair & Scalp Clinic Dartford
Hair Loss and Scalp Problem Consultation Form
Select the reason for requesting a consultation:
*
Hair Loss
Scalp Problem
Hair Damage
Hair Transplant Surgery
I am a returning client/patient
Other
Title:
*
Name:
*
First Name
Last Name
Date of Birth:
*
-
Day
-
Month
Year
Date
Address:
*
Sex:
*
Male
Female
Prefer not to say
Other
Phone Number:
*
-
Area Code
Phone Number
Email Address:
*
example@example.com
GP Doctors details:
*
Previous Trichologist, Dermatologist:
*
Occupation:
*
Does your job involve working with chemicals?
*
Yes
No
Are you a past patient?
*
Yes
No
Upload images of your profile and hair or scalp problem:
*
Browse Files
Drag and drop files here
Choose a file
You can upload multiple files here
Cancel
of
HAIR: Please explain the problem with your hair:
*
When did the hair problem start?
-
Day
-
Month
Year
Date
What is the current condition of your hair?
*
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:
*
Caucasian
Afro
Asian
Mixed
How long is your hair?
*
Please Select
Short
Medium
Long
I don't have any hair
Is there a history of hair loss in the family?
*
No
Yes
SCALP: Please explain the problem with your scalp:
*
When did the scalp problem start?
-
Day
-
Month
Year
Date
What is the current condition of your scalp?
*
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?
*
No
Yes
Is there a history of skin problems in the family?
*
No
Yes
Do you have any finger or toe nail problems?
*
Yes
No
When did you last visit a doctor, dermatologist, trichologist, specialist about your hair or scalp problem?
-
Day
-
Month
Year
Date
What diagnosis were you given?
*
ALLERGIES: Please list all allergies, including foods, fluids, medicines, cosmetics, if none, state N/A:
*
HEALTH: Do you have any problems with the following?
*
Thyroid or Endocrine
Epilepsy, Giddiness, Blackouts
Liver, Kidney, Bowel, Digestive
Asthma, Bronchitis, Chest problems
Diabetes: Type 1 or 2
HIV or Hepatitis
Cancer, Chemotherapy, Radiotherapy
Arthritis, Bone issues
Blood pressure or Stroke
Heart problem
Covid
Eyes: Glaucoma, other problems
N/A
Pacemaker
Other
HEALTH BLOOD: Do you have any problems with the following?
*
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.
*
Please list any Vitamins / Minerals you are currently taking, if none, state N/A:
*
HEALTH: Any major illnesses or accidents and if so what?
*
No
Yes
SCALP SURGERY: Have you had any surgery for?
*
Hair Transplant
Scalp or Brain Surgery
N/A
Other
List any surgeries for medical and/or cosmetic reasons, if none, state N/A:
*
HEALTH MENTAL: Any problems with the following?
*
Stress, Anxiety
Abuse
Trauma, Shock
N/A
Other
HEALTH DIET: Have you?
*
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?
*
Yes
No
HEALTH: Do you drink alcohol?
*
Yes
No
HEALTH WOMEN: Do any of the following apply?
*
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?
*
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?
-
Day
-
Month
Year
Date
What shampoo do you use?
*
What conditioner do you use?
*
Please list hair styling products you're currently using, if none, state N/A:
*
Do you use hot irons?
*
No
Yes, how often?
How did you hear about us?
*
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.
*
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
Print Form
Submit
Submit
Should be Empty: