Hair Loss Questionnaire

Hair Loss Questionaire

Please take a few moments to answer all questions as truthfully as possible. This information will help us to build a treatment plan as quickly as possible.
Name

First NameLast Name
Email
example@example.com
Cell Phone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Allergies
Food Allergies
Are you allergic to shellfish
Surgery with anesthesia in the past 2 years?
Do you have any of the following:

AnemiaPCOSHigh blood pressureSkin DisordersThyroid IssuesAcid RefluxDiabetesAutoimmune
Are you in peri-menopause or menopause?
Have you had a hysterectomy?
Have you been diagnosed with Alopecia Areata?
Do you smoke/vape?
Have you seen a dermatologist for your hair loss?
How would you rate your stress level?
(1 being low, 5 being high)

Heredity
Does hair loss run in your family?
Have you used Minoxidil?
Have you used prescriptions for hair loss?
Have you had PRP treatments for hair loss?
What hair loss products have you used?
Consent for Treatment
During the evaluation and recheck appointments, digital pictures and microscope pictures will be taken and stored in a personal file for which I give my consent.
I give my consent to use my digital pictures on social media

with my facewith my face blurred
I understand it is my responsibility to communicate with my medical provider before adding supplements with current medications.

I understand that Stephanie's recomendations should not be a substitute for medical advice from a physician.

By agreeeing 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 and Doctor of any changes in my condition, no matter how slight.
Signature

Clear
Date

MonthDayYear
Date
Thank You!
Should be Empty:

Hair Loss Questionaire