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.
  • How do you identify?*
  • Are you post-menopausal?*
  • Are you currently pregnant or nursing?*
  • Are you planning to get pregnant in the next 6 months?*
  • Do you take contraceptive pills?*
  • Have you, or do you plan to, take a PSA blood test for the screening of prostate cancer?*
  • Do you have an enlarged prostate or prostate cancer?*
  • Are you vegan/vegetarian?*
  • Is your scalp:*
  • Are you experiencing redness or an itchy scalp?*
  • Do you pull your hair?*
  • Are you experiencing any bumps or raised areas on your scalp?*
  • Are you experiencing hair loss?*
  • Is your hair loss patchy?*
  • What areas of your head are you experiencing hair loss?*
  • Are you experiencing hair loss on other parts of your body?*
  • Was it sudden or gradual?*
  • Is your hair loss caused by a medical condition or medication?*
  • Is your hair loss getting worse?*
  • Does hair loss run in your family?*
  • How much does this bother you?*
  • When your hair is wet, do you use a towel to rub dry?*
  • Do you use a hair (sit under) dryer?*
  • What temperature do you use?*
  • Do you color your hair?*
  • Treatment may take 6 months or more to show success, are you willing to wait that long?*

  • 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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