Confidential Consultation for Hair Loss

Confidential Hair Loss Consultation Questionnaire

Please answer all questions to the best of you ability. The more information you share the easier it is for me to give you the best recommendations!
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
Age
What is your Instagram @?
What is your occupation? (Some occupations expose people to toxic chemicals: graphic artists working with dyes or pigments, auto mechanics / auto body repair who work with paints or solvents, hair stylist, office workers who are exposed to toner from copiers, etc. Or have a high stress level: lawyers, sales, police, and students)
Allergies:
Are you allergic to shellfish?
Tell me about your General Health:
Recent Surgery with General Anesthesia; (Especially recent surgery as general anesthesia or the stress of the surgery may cause a shed. Important to know if a woman has had a hysterectomy which will cause some hormonal shift even if she is on hormone replacement therapy.)
Do you have any of these following issues?

Other
Presently undergoing treatment for:
Physicians Name:
Date of last physical:
Stress Level (Stress is a big factor in hair loss, especially for women and may cause telogen effluvium. This condition even with treatment may take up to 16 weeks to reverse.)
Please list any medications: (Many medications may cause hair loss as a side effect. Most common are anti-coagulants such as heparin, warfarin (Coumadin), Anti-depressants, hormones (birth control as well as HRT), some thyroid medications, and statins (cholesterol lowering drugs). CLIENTS SHOULD NEVER STOP MEDICATIONS WIHTOUT CONSULTING THEIR DOCTOR!)
Please list any supplements:
Does Hair loss run in your family? Parents? Grandparents? Siblings? Aunts? Uncles?
Females Only

Other
Males Only: Have you had the PSA blood test to screen for Prostate cancer? (Men who have enlarged prostate or are being checked (PSA) for enlarged prostate, need to let their doctor know they are taking an “anti-androgen (saw palmetto) (XTC’s Supplements) or “Propecia™/Finasteride) as they may cause the PSA to have lower value than it really is. The doctor may suggest he discontinue taking the supplement for a week or two, prior to having this test performed; for a more accurate reading of their level.)
Nutrition: Are you Vegetarian?
How many Daily servings are you getting of Protein, Fruit, Vegetables, Caffeine, Carbohydrates? (Diet is particularly important for healthy hair. An adequate protein intake is essential. How much a person needs per day is based on body weight at .8g per kilogram (2.2lbs). The only contraindication on this is a person who needs to restrict protein intake such as someone with kidney disease.Vegetarians who do not eat any kind of animal protein will have a difficult time with adequate protein as there are two types of protein- complete (animal based such as meat, fish, and poultry which includes dairy products and eggs) and incomplete (nuts, legumes, soy, etc)Fruits and vegetables are important, and people should eat a variety of colors for the best nutritional value.Caffeine (coffee, tea, colas, chocolate, energy drinks) interferes with how your body processes B vitamins so excessive use should be avoided. Anyone who has lost a lot of weight in a short period of time (diet, gastric bypass, or bariatric surgery) will lose hair.)
Have you lost weight recently, and if so, how much?
How much does your hair loss bother you?
My scalp and hair at the roots is:
Do you have any scalp conditions? redness, itching, bumps or raised areas, recurrent attacks of patchy loss, hair of different lengths, and tell me what area of your head you are experiencing hair loss.
At what age did you notice hair loss? Was it sudden or gradual?
Is your hair loss getting worse? How many hairs per day do you think you are loosing?
What options have you researched for your hair loss?

Other
What are your goals and expectations?

Other
Please indicate where your hair loss bothers your the most:
What Shampoo, Conditioner and Styling products are you currently using?
Do you shampoo daily? If not, how often?
The length of your hair, is it:

Other
What chemical services have been sone to your hair in the last year.

Other
How do you style?

Other
Any other hair woes?? Or what do you love about your hair?
Any other skin concerns you'd like me to know?
How did you find out about me?
Should be Empty:

Confidential Hair Loss Consultation Questionnaire