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
Name
First Name
Last Name
Phone Number
Email Address
example@example.com
Address
Occupation
Date of Birth
-
Month
-
Day
Year
Date
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?
-
Month
-
Day
Year
Date
What is the current condition of your hair?
Hair loss -thinning - Patchy hair loss
Split ends
Damage due to heat
Breakage
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
Other
How long is your hair?
Please Select
Short
Medium
Long
I don't have any hair
SCALP: Please explain what is the problem with your scalp
When did the scalp problem start?
-
Month
-
Day
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
Other
Kindly describe the status of your scalp.
Please Select
Dry
Normal
Oily
Weepy
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
Major illness
Covid
Eyes: Glaucoma, other problems
Other
HEALTH MENTAL: Any problems with the following?
Stress, Anxiety
Abuse
Trauma, Shock
Other
HEALTH BLOOD: Do you have any problems with the following?
Anaemia
Sickle cell anaemia
Thalassemia
Other blood disorder
Other
HEALTH SURGERY: Have you had any surgery for?
Hair Transplant
Scalp or Brain Surgery
Other Medical reasons
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
Other
HEALTH: Women do any of the following apply?
Currently Pregnant
Breast feeding
Had a baby in the last 2 years
Other
How often do you apply shampoo and conditioner in your hair?
Every day
Every other day
Twice a week
Once a week
Other
Have you used the following in your hair before?
Permanent hair colour
Keratin Treatment
Semi-permanent colours
Relaxer
Perms
Bleach
Other
When did you last colour, perm, bleach, keratin or relax your hair.
-
Month
-
Day
Year
Date
When did you last visit a doctor, dermatologist, trichologist, specialist about your hair or scalp problem?
-
Month
-
Day
Year
Date
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?
Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
Any special instructions, comments, or suggestions?
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