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.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Occupation
Referred by
What is your primary concern?
When did these concerns start?
Was there anything significant in your life around this time? (pregnancy, surgery, stress, illness, etc)
HAIR & SCALP CONDITIONS
Describe the pattern of your hair loss
Is your hair loss
When did you first notice hair loss?
Is your scalp
Do you experience any of the following scalp symptoms?
Have you ever been diagnosed with a scalp condition?
If yes, please specify
Have you ever had a biopsy?
If yes, please specify
Check all that apply
Medical History
How would you describe your general health status?
General health conditions. (Check all that apply)
If yes to autoimmune, which one have you been diagnosed with?
If other, please specify
High impact history (Check all that apply)
Digestive Health (Check all that apply)
If yes to food allergies, please list
Environmental and dental
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 and brands.
Allergies
Are you allergic to shellfish
Do you have any of the following:
LIFESTYLE FACTORS
Are you a vegetarian/vegan?
Daily protein intake?
Daily water intake?
How many hours of sleep do you usually get?
How would you rate your quality of sleep?
How would you rate your stress level?
(1 being low, 10 being high)
Do you exercise? If so, how often and what types of workouts?
Do you smoke/vape?
Average daily caffeine intake
HORMONE RELATED
Current status (Check all that apply)
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 CARE PRACTICES
How often do you shampoo your hair?
List hair care products currently using
Do you use any of the following hair treatments?
Have you ever experienced adverse reactions to hair treatments?
PREVIOUS HAIR LOSS TREATMENTS
Have you tried any hair loss treatments in the past?
If other, please specify
If you tried treatments, did you notice any improvement?
If yes, please describe
FAMILY HISTORY
Does hair loss run in your family?
If yes, please specify which relatives and what type of hair loss
TREATMENT GOALS & PREFERENCES
What are your primary goals for this treatment? (Select up to 3)
How much does your hair loss bother you?
1 being little, 10 being a lot
Knowing that meaningful results often take 6 - 12 months or more, are you willing to commit?
Do you have any indication or theory of where your hair loss or scalp condition may be from?
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
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 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 and doctor of any changes in my condition, no matter how slight.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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)
Areas of loss
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

HAIR & SCALP CONDITIONS

Medical History

LIFESTYLE FACTORS

HORMONE RELATED

HAIR CARE PRACTICES

PREVIOUS HAIR LOSS TREATMENTS

FAMILY HISTORY

TREATMENT GOALS & PREFERENCES

CONSENT

Thank You!