Scalp Analysis Digital Consultation Form

Scalp Analysis Digital Consultation Form

Kudos to you for prioritizing the health of your scalp and hair! All new Scalp Therapy guests start working with me here with a digital consultation form. This allows me to learn about your concerns, what you're currently experiencing, and make recommendations with this information. Please complete the form in full and to the best of your ability. If you have any questions or need support, please email me at support@stylesbyz.com. I’ll be in touch within 24 hours during my work week, which is Tuesday-Friday. All emails received Saturday-Monday will be responded to on Tuesday.
What is your full name?*

First NameLast Name
How do you identify?*

Biologically MaleBiologically Female
Are you post-menopausal?*

YesNo
Are you currently pregnant or nursing?*

YesNo
Are you planning to get pregnant in the next 6 months?*

YesNo
Do you take contraceptive pills?*

YesNo
How long have you been taking them?*
Have you, or do you plan to, take a PSA blood test for the screening of prostate cancer?*

YesNo
Do you have an enlarged prostate or prostate cancer?*

YesNo
How would you describe your overall health?*
Do you have any allergies?*
Do you have any of the following conditions? (Select all that apply.)*
Please tell me more.*
Are you currently undergoing treatment for a medical condition? *
Please tell me more.*
Have you recently had surgery with general anesthesia? *
How would you classify your stress level?*
Please list any medications you may be taking, including multivitamins.*
Are you vegan/vegetarian?*

YesNo
How many daily servings of fruits and vegetables do you eat?*
How much water do you drink and how often?*
Is your scalp:*

DryOilyNormal
Are you experiencing a scalp condition(s) (i.e., dry scalp, dandruff, etc.)?*
Are you experiencing redness or an itchy scalp?*

YesNo
Do you pull your hair?*

YesNo
Are you experiencing any bumps or raised areas on your scalp?*

YesNo
Are you experiencing hair loss?*

YesNo
Is your hair loss patchy?*

YesNo
What areas of your head are you experiencing hair loss?*

All overThe topThe crownThe frontMy temples (edges)
Are you experiencing hair loss on other parts of your body?*

YesNo
Please tell me more.*
At what age did you notice your hair loss?*
Was it sudden or gradual?*

SuddenGradual
Is your hair loss caused by a medical condition or medication?*

YesNoI don't know
Please tell me more.*
Is your hair loss getting worse?*

YesNo
Does hair loss run in your family?*

YesNoI don't know
How much does this bother you?*

SlightlyModeratelyI'm very bothered
Please tell me more.*
What have you tried to combat this (i.e., products, wigs and weaves, etc.)?*
What kind of shampoo and conditioner do you use?*
How often do you shampoo your hair?*
When your hair is wet, do you use a towel to rub dry?*

YesNo
Do you use a hair (sit under) dryer?*

YesNo
What temperature do you use?*

HotMediumCool
Do you color your hair?*

YesNo
How often do you color your hair?*
Is there anything else I should know before your appointment?
Treatment may take 6 months or more to show success, are you willing to wait that long?*

YesNo
By completing this form, I am agreeing to being evaluated.

I acknowledge that I have answered truthfully and to the best of my ability.

I understand that the Trichologist's conclusions and recommendations will be based on my responses, in addition to my scalp analysis; which will include digital and microscopic pictures of my scalp, for which I give consent.

I further understand that results will vary depending on a large number of factors, and it is my responsibility to communicate any changes in my condition, no matter how slight.

By clicking the submit button below, I agree to these terms.
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