Hairloss Client Intake Form

Contact & Profile Information:
Full Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Current Age
Gender
What is your occupation?
Your Hair & Scalp Care Practices
List any shampoos, conditioners, or styling products you currently use*
How often do you shampoo your hair?*
What styles have you worn in the past? *

BraidsWeavesPonytailsCrochet BraidsInter LocsTwisted LocsFreeform LocsWash and GoTwists OutsOther
Choose all that you are currently using:*

WigsHair FibresDyesBraidsWeavesFlat-ironTexturizersPonytailsKeratin/Japanese TreatmentsHair Fiber/ConcealerOther
How often do you use heat on your hair? (blow dry, flat iron, curling iron)*
When was your last perm (relaxer)*

NeverLess than a year ago1-3 years agoMore than 3 years ago
How often do you dye your hair?*
Hairloss
When did you FIRST notice that you were losing your hair?*
mm-dd-yyyy
Have you experienced any of the following on your scalp? Choose all that applies.*

DryOilyFlaky/CrustySoreBruisedRed/InflamedDandruffItchyPimplesBurningTinglingTendernessPainOther
What areas have you noticed hairloss?*

Right TempleLeft TempleCrownBackAbove EarsAll over the entire scalpOther
Please upload any images of your hair you would like to share

Browse Files

Cancelof
If you've lost more hair during the past 6 12 months please explain
If you've notice anything else about your scalp please explain:
Has your hair texture changed?*

YesNoUnknown
Are you currently being treated by a dermatologist?*

YesNo
Has a biobsy been done on your scalp?*

YesNoCan't Recall
If you were diagnosed with any type of Alopecia (hair loss) please state the type.
If you've ever received scalp injections or taken any medications for the hair loss please explain.
Please describe and list all the prescription and non-prescription treatments that you have tried for your hair loss condition:
List ALL medication you are currently taking.
If you have unwanted or excessive hair growth on your body, please state where.
Have you experienced any changes in your nails?*

YesNo
If so are there any visible lines from top to bottom?*

YesNo
Diet & Supplementation
Do you have any allergies?*

YesNo
Which of the following best describes your current diet?*

Low fatNo GluetenNo DairyNo WheatHigh ProteinDiabeticNoglutenVeganPescatarianVegetarianStandard American DietOther
Has your diet changed within the past year?*

YesNo

How often do you consume the following:

	Ofen	Sometimes	Rarely	None
Tofu
Dairy
Chicken
Beef
Pork
Rice
Pasta
Sugar
Soda
Coffee

What supplements have you consumed within the past 6-8 months?*

IronB12ZincBiotinOmega 3Vitamin D3MagesiumNone
If you are taking hair growth supplements please state the brand name(s).
Health & Lifestyle
Please provide your blood type.
Have you donated blood within the past 2 years?*

YesNo
Do you sleep well?*

YesNo
Which of the following do you partake in?*

MeditationYogaTai ChiWeight TrainingAreobicsNoneOther
Have you used anabolic steroids?*

YesNo
Do you have dry skin or rashes on your body?*

YesNo
Were you ever informed that you have a thyroid condition?*

YesNo
Have you ever been treated with thyroid hormones?*

YesNo
If your hormones have been tested otherwise please explain:
Have you ever been informed by a doctor that your iron levels are low?*

YesNo
If so when?
Approximately
If you've undergone treatment for any ailment during the last six months, please select what applies.*

Heart TroubleHypertensionLow Blood PressurePituitary ImbalanceBlood DisorderSeizure DisorderDiabetesKeloidPsoriasisSkin or Scalp Disorder(s)Other
Have you been hospitalized prior to or during the hair loss?*

YesNo
Have you experienced illness prior to or during the hair loss?*

YesNo
Please state any medical issues you have:
Have you been under severe stress prior to or during the hair loss?*

YesNo
Please select any condition your family member(s) experience(d).

LupusRheumatoid ArthristisCeliac DiseaseType I DiabetesSjogrens DiseaseVitiligoOther
Thank you for taking the time to complete our Hair Loss Questionnaire. If you haven't already done so, please book a consultation. Your time and patience are greatly appreciated!
Should be Empty:

Contact & Profile Information:

Hairloss

Diet & Supplementation

Health & Lifestyle