Hair & Scalp Consultation Form

Hair & Scalp Clinic Dartford

Hair Loss and Scalp Problem Consultation Form
Select the reason for requesting a consultation:*

Hair LossScalp ProblemHair DamageHair Transplant SurgeryI am a returning client/patientOther
Title:*
Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Address*

Address Line 1

Address Line 2

CityCounty

Post Code
Sex:*

MaleFemalePrefer not to sayOther
Phone Number:*

Area CodePhone Number
Email Address:*
example@example.com
GP Doctors details:*
Occupation:*
Does your job involve working with chemicals?*

YesNo
Are you a past patient?*

YesNo
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:*

You can upload multiple files here
Cancelof
HAIR: Please explain the problem with your hair:*
When did the hair problem start?

DayMonthYear
Date
What is the current condition of your hair?*

Hair loss - thinningPatchy hair lossSplit endsDamage due to heatBreakageDamage due to chemicalsHair is dryI don't have any hairI pull out my own hairIncreased shedding of hairOther
Hair type:*

CaucasianAfroAsianMixed / Other
How long is your hair?*
Is there a history of hair loss in the family?*

NoYes
SCALP: Please explain the problem with your scalp:*
When did the scalp problem start?

DayMonthYear
Date
What is the current condition of your scalp?*

FlakyPustules - SpotsDandruffSore - Painful scalpItchy scalpI pick, scratch rub my scalpDryNormalOilyOther
Do you have any skin problems?*

NoYes
Is there a history of skin problems in the family?*

NoYes
Do you have any finger or toe nail problems?*

YesNo
When did you last visit a doctor, dermatologist, trichologist, specialist about your hair or scalp problem?

DayMonthYear
Date
Who did you visit about your hair or scalp problem?*

DoctorDermatologistN/ATrichologist and Name
What diagnosis were you given?*
HEALTH: Do you have any problems with the following?*

Thyroid or EndocrineEpilepsyBowel, DigestiveAsthma, Bronchitis, Chest problemsDiabetes: Type 1 or 2HIV or HepatitisCancer, Chemotherapy, RadiotherapyArthritis, Bone issuesBlood PressureHeart problemCovidEyes: Glaucoma, other problemsN/APacemakerGiddinessBlackoutsLiverKidneyStrokeOther
HEALTH BLOOD: Do you have any problems with the following?*

AnaemiaSickle cell anaemiaThalassemiaN/AOther
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?*

NoYes
SCALP SURGERY: Have you had any surgery for?*

Hair TransplantScalp or Brain SurgeryN/AOther
List any surgeries for medical and/or cosmetic reasons, if none, state N/A:*
HEALTH MENTAL: Any problems with the following?*

Stress, AnxietyAbuseTrauma, ShockN/AOther
HEALTH DIET: Have you?*

Lost weight in the last yearGained weight in the last yearAre you dietingVegetarian, veganSpecial health reason dietN/AOther
HEALTH: Do you smoke/vape?*

YesNo
HEALTH: Do you drink alcohol?*

YesNo
HEALTH WOMEN: Do any of the following apply?*

Currently PregnantBreast feedingHad a baby in the last 2 yearsOn a contraceptive pillHad a HysterectomyOn HRTN/AOther
Have you used the following on your hair before?*

Permanent hair colourKeratin TreatmentSemi-permanent coloursRelaxerPermsBleachN/AOther
When did you last colour, perm, bleach, keratin or relax your hair?

DayMonthYear
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?*

NoYes, how often?
How did you hear about us?*

FacebookTwitterInstagramYouTubeOnline AdvertisementGoogle SearchReferred by a friendNewspaper/MagazineOther
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:*

DayMonthYear
Date
Are you completing this form on behalf of someone else?*

NoYes, enter your name and relationship to the person
Should be Empty:

Hair & Scalp Clinic Dartford