Hair Loss Consult Questionnaire

Name
Date

MonthDayYear
Date
Email
example@example.com
Date of Birth

MonthDayYear
Date
Referred by
Allergies
Food Allergies
Are you allergic to shellfish?

YesNo
Any previous surgery with Anesthesia ? ( in the past 2 yrs)

YesNo
Do you have any of the following

High Blood PressureAnemiaDiabetesHeartSkin DisorderAcid RefluxThyroidPCOSDiabetesAuto Immune
Have you had a biopsy? Results
Have you had a biopsy

YesNo
If yes Results:
Are you in Peri Menopause or Menopause?
Have you had Covid-19?

YesNoType option 3Type option 4
How long ago?
Have you had any of the Covid-19 vaccines? Which one
Have you been diagnosed with Alopecia Areata (AA)?

YesNO
Have you seen a dermatologist for your hair loss?

YesNo
If yes Presently going under treatment for
Rate your stress level ( 1: Low 5 High)
Supplement(s): (Pease list by name)
Medication(s): (Pease list by name)
Are you Vegetarian/Vegan

YesNO
How would you describe your hair?

DryOilyNormalDandruff
Do you have an itchy scalp
Do you have bumps or raised areas?
Crawling Sensation

TinglingBurning
What areas?
Recurrent attacks of patchy loss
Do you have hair of different lengths falling out? Should be when your hair falls out are all the hairs one length or are there shorter ones also?
What area(s)on your head?
Do you notice any of the following about your hands

RednessColdscales
Do you notice any of the following about your Nails?

BrittleYellowBlacklinesPitted NailsRidgesPeeling
Areas oof Hair loss

All over scalpFrontCrown
What age did you notice your hair loss
Was is Sudden or Gradual?
How many hairs do you lose per day?

50 or lessmore than 50100 or morenot sure but seems like alot
Is your Hair Loss getting worse?

YesNonot sure
Do you have any hair loss on the body?

YesNo
If yes what areas?
What kind of Shampoo/Conditioner do you use?
How many times a week do you shampoo?

Daily3 times a week2 times a weekOnce a week
Is your hair loss concern caused by any medical problems or medications that you are aware of?
Do you use a hair dyer?

YesNo
Hair dryer Setting Level
Have you had a reaction to color?

YesNo
Have you had any of the following

DreadlocksBraidsHair extensionsGlue on wig
If yes, for how long?
Does Hair loss run in your family? ( It can go back as far as your grandparents)

YesNo
Have you used prescriptions for hair loss?

YesNo
Have you use Minoxidle?

YesNo
Have you had PRP treatments for hair loss?

YesNo
What Hair I loss products have you used?
Please indicate where hair loss bothers you the most:

Going outdoors on a windy daySeeing photosSocial LifeParticipating in sportsSwimmingPeople make commentsAppearance at workOverall AppearanceSeeing old friends
Consent for treatment:

During the evaluation and recheck appointments, digital pictures and microscopicpictures will be taken and stored in a personal file for which i give my consent. I give my consent to use digital pictures on social media _____with my face. _____with my face blurred

Iunderstand it is my responsibility to communicate with my medical providerbefore adding any supplements with current medications.

I understand that Kerri's recommendations should not be a substitute for medical advice by my physician. By agreeing to these terms, I further understand that results will vary depending on a large number of factors and I acknowledge that it is my responsibility to inform my Hair Loss Specialist/Trichologist & Dr. of any changes in my condition, no matter how slight.
Signature

Clear
Date

MonthDayYear
Date
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