Hair Loss Questionnaire

Hair & Scalp Analysis Intake Form

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
Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Occupation
Referred by

Physician or medical referralGoogleSocial MediaFriend or Family memberBeauty professionalReturning ClientOther
Medical History
How would you describe your general health status?

ExcellentGoodFairPoor
Do you have / have you had any of the following?

Hypertension (High Blood Pressure)DiabetesThyroid Disorder (Hypothyroidism, Hyperthyroidism, Hashimoto’s, Graves’)Autoimmune DiseasePolycystic Ovary Syndrome (PCOS)Anemia (Iron Deficiency, B12 Deficiency, etc.)Chronic Stress or AnxietyRecent Illness or Infection (COVID-19, Flu, etc.)Hormonal Imbalance (Estrogen, Testosterone, DHEA, etc.)None of the aboveOther
If yes to autoimmune, which one have you been diagnosed with?
If other, please specify
Nails (Select all that apply)

BrittleYellowBlacklinesPittenailsRidgesPeelingHalf moons
List any surgeries within the past two years
Are you currently taking any prescribed or over-the-counter medications? If yes, please list all medications.
Do you take any nutritional supplements regularly? If yes, please list all supplements.
Allergies
Food Allergies
Are you allergic to shellfish
Surgery with anesthesia in the past 2 years?
How would you rate your stress level?
(1 being low, 10 being high)
NUTRITION
Do you have any of the following:

AnemiaPCOSHigh blood pressureSkin DisordersThyroid IssuesAcid RefluxDiabetesAutoimmune
Are you a vegetarian/vegan?
Are you eating protein everyday?
LIFESTYLE FACTORS
Do you smoke/vape?
Average daily caffeine intake

None1 cup2 cups3 cups4+ cups
HORMONE RELATED
Are you pregnant or nursing?

PregnantNursingBothNeither
Have you experienced recent hormonal changes?

PostpartumPerimenopauseMenopausalIrregular menstrual cyclesNone
Are you currently using birth control?
If yes, please specify type and duration
Are you planning to become pregnant within the next six months?
Have you ever taken hormone replacement therapy (HRT)?
If yes, please specify
HAIR & SCALP CONDITIONS
When did you first notice hair loss?

Less than 6 months ago6 - 12 months ago1 – 3 years ago3+ years ago
Describe the pattern of your hair loss

Receding hairlineBald patchesAll over thinning
Do you have recurrent attacks of patchy loss?
Is your hair loss

SuddenGradual
Do you experience any of the following scalp symptoms?

ItchingRednessFlakingTendernessTingly sensationBurning sensationNone
Is your scalp

DryOilyNormalDandruff
Have you ever been diagnosed with a scalp condition?
If yes, please specify
Have you ever had a biopsy?
If yes, please specify
Do you pull your hair?
Do you have any indication or theory of where your hair loss or scalp condition may be from?
HAIR CARE PRACTICES
How often do you shampoo your hair?

DailyEvery other day2 - 3 times a weekOnce per week or less
List hair care products currently using
Do you use any of the following hair treatments?

Hair color or highlightsRelaxersPermsHeat styling toolsHair ExtensionsTight hairstyles (ponytails or braids)
Have you ever experienced adverse reactions to hair treatments?
Do you blow dry your hair?
PREVIOUS HAIR LOSS TREATMENTS
Have you tried any hair loss treatments in the past?

Rogaine / MinoxidilFinasteride / PropeciaExosomes or Growth FactorsLow Level Laser Therapy (laser cap)MicroneedlingWigs / toppers / extensionsTransplantSupplementationOther
If other, please specify
If you tried treatments, did you notice any improvement?
If yes, please describe
How much does your hair loss bother you?
1 being little, 10 being a lot
FAMILY HISTORY
Does hair loss run in your family?
If yes, please specify
TREATMENT GOALS & PREFERENCES
What are your primary goals for this treatment? (Select up to 3)

Slowing hair lossStimulating new hair growthImproving scalp healthReducing scalp irritation or inflammationStrengthening existing hairQuickly growing hair backDetoxifying scalp buildupLearning better scalp and hair care routines
Knowing that treatment may take 6 months or more to show success, are you willing to commit?
Please indicate where hair loss bothers you the most (select all that apply)

No variation in hairstyleBeing outside on a windy daySocial lifeSeeing old friendsOverall appearanceConscious of appearance at workSeeing pictures / videosWearing hats when going outSwimming or getting caught in the rainOverall self-esteemMeeting new peoplePeople making comments
CONSENT
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
Date

MonthDayYear
Date
Thank You!
Are you in peri-menopause or menopause?
Have you had a hysterectomy?
Have you been diagnosed with Alopecia Areata?
Have you seen a dermatologist for your hair loss?
Supplements (Please list by name)
Medications (Please list by name)
That you are aware of, is your hair loss due to medical problems or medication?
Do you have itchy scalp?
Do you have bumps or raised areas?
Do you lose different lengths of hair?
Do you have crawling sensations? Such as itching or burning?
If yes, what areas?
Hands (select all that apply)

ColdRednessScales
Areas of loss

All over scalpFrontCrownBack or Sides
Was hair loss sudden or gradual?
Do you have hair loss on the body?
What kind of shampoo and conditioner do you use?
How many times per week do you shampoo?
Do you use a hair dryer and if yess what setting?
Have you had a reaction to hair color? If yes, please explain.
Have you ever had long term extensions, braids, or dreadlocks?
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?
Should be Empty:

Hair & Scalp Analysis Intake Form

Medical History

NUTRITION

LIFESTYLE FACTORS

HORMONE RELATED

HAIR & SCALP CONDITIONS

HAIR CARE PRACTICES

PREVIOUS HAIR LOSS TREATMENTS

FAMILY HISTORY

TREATMENT GOALS & PREFERENCES

CONSENT

Thank You!