Hair & Scalp Clinic Dartford
Hair Loss and Scalp Problem Consultation Form
Select the reason for requesting a consultation.
Hair Transplant Surgery
I am a returning client/patient
Date of Birth
Gp Doctors details
Previous Trichologist, Dermatologist
How did you hear about us
Upload an images of your profile and hair or scalp problem
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HAIR: Please explain what is the problem with your hair
When did the hair problem start?
What is the current condition of your hair?
Hair loss -thinning - Patchy hair loss
Damage due to heat
Damaged due to chemicals
Hair is dry
Hair is Afro tight curls
I don't have any hair
Hair is curly - wavy
I pull out my own hair
Hair is naturally straight
How long is your hair?
I don't have any hair
SCALP: Please explain what is the problem with your scalp
When did the scalp problem start?
What is the current condition of your scalp?
Pustules - Spots
Sore - Painful scalp
I pick, scratch rub my scalp
Kindly describe the status of your scalp.
HEALTH GENERAL: Do you have any problems with the following?
Thyroid or Endocrine
Epilepsy, Giddiness, Blackouts
Liver, Kidney, Bowel, Digestive
Asthma, Bronchitis, Chest problems
Diabetic: Type 1 or 2
HIV or Hepatitis
Cancer, Chemotherapy, Radiotherapy
Arthritis, bone issues
Blood pressure or Stroke
Heart problem, Pacemaker
Eyes: Glaucoma, other problems
HEALTH MENTAL: Any problems with the following?
HEALTH BLOOD: Do you have any problems with the following?
Sickle cell anaemia
Other blood disorder
HEALTH SURGERY: Have you had any surgery for?
Scalp or Brain Surgery
Other Medical reasons
HEALTH DIET: Have you?
Lost weight in the last year
Gained weight in the last year
Are you dieting
Special health reason diet
HEALTH: Women do any of the following apply?
Had a baby in the last 2 years
How often do you apply shampoo and conditioner in your hair?
Every other day
Twice a week
Once a week
Have you used the following in your hair before?
Permanent hair colour
When did you last colour, perm, bleach, keratin or relax your hair.
When did you last visit a doctor, dermatologist, trichologist, specialist about your hair or scalp problem?
ALLERGIES: Please list all allergies, including foods, fluids, medicines, cosmetics
Are you currently taking any medications, drugs Internally or externally? If yes, please list them below, if not, leave it blank.
Please indicate the list of hair and scalp products you're currently using:
How did you hear about us?
Referred by a friend
Any special instructions, comments, or suggestions?
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