Fillable Consult Questionaire

Name*
Birthdate*

MonthDayYear
Date
Address*
Email*
example@example.com
Phone*
In Case of Emergency whom shall I contact First Name Last Name . Phone Numb Area Code Phone Number .
Preferred Way of Communication*

Vidoe CallTextEmail
Referred By
SalonFacebook
Referred By*

WebsiteInstagram
Are you aware that payment plans are available?*

YesNo
Chief complaints: Describe in your own words sort of hair treatment(s) you’re interested in (or those you are NOT) at Ker About Your Hair LLC: *
Current Medication(s): (Pease list by name)*
Current Supplement(s): (Pease list by name)*
HISTORY OF HAIR AND SCALP HEALTH
When did your hair loss start (approximately)(if any)?*
Was the onset of hair loss*

SuddenGradualNone
Area(s) of Hair Loss*

All over scalpFrontCrownNone
Do you have any Hair Loss on the body?*

YesNo
If yes what areas ?
Since onset, has it gotten: ?*

BetterWorseAttacks of Patchy LossesStayed the SameNone
Is your Hair:*

ThinningSheddingBothNone of the above
Do you have an itchy scalp?*

MildModerateServereNO
Is your scalp:*

OilyDryNormalDandruff
Is your scalp:*

YesNo
When you hair falls out (sheds) are they in different lengths ( one length and/or shorter ones)*

YesNo
Do you pull your hair?*

YesNo
Do you feel any of these things on your scalp*

Crawling SensationTingling SensationBurning SensationNone
Does Hair Loss run in your family?*

YesNo
Approximately how many hairs do you think you lose a day? ( Normal Hair Loss is 50- 150 a day)*
HISTORY OF HAIR STYLING
How many times a week do you shampoo?*
What kind of shampoos/conditioner do you use?*
Do you use a hair dryer?*

YesNo
Setting level*

HotMediumcool
Have you ever had a reaction to color?*

YesNo
Have you had any of the following*

DreadlocksTight braidsHair ExtensionsGlued on WigNever had any
Is you Hair Loss concern caused by any medical problems of medications that you're aware of?*
HEALTH HISTORY
Have you recently dramatically changed your diet?*

YesNo
Are you a Vegetarian?*

YesNoOther
Have you had COVID and/or shots?*

YesNo
Are you on any type of hormone treatment?

YesNo
Are you allergic to Shellfish?*

YesNO
Previous surgeries with Anesthesia in the last 2 years?*

Yes:No:
Do you have any of the following*

Anemia:Skin Disorder:Thyroid:PCOS:Autoimmune:Acid Reflux:Acid Reflux:Diabetes:High Blood PressureNone
Have you had a biopsy? Results*

YesNo
Results from biopsy if any
Are you Peri-Menopause or Menoapuse*

YesNo
Have you had a Hysterectomy?*

YesNo
Have you been diagnosed with Alopecia Areata?*

YesNo
Do you smoke or vape?*

YesNo
Have you seen a dermatologist for your hair loss?*

YesNo
Presently going under treatment from dermatologist for if any*
Rate your stress level: (1: LOW 5:HIGH)*

12345
Are you a Vegetarian/Vegan*

YesNo
Do you have any of the following issues with your hands?*

ColdRednessScalesNone
Do you have any of the following issues with your nails?*

BrittleYellowingBlacklinesPittennailsRidgesPeelingHalf moonsNone
Have you ever uses Minoxidil?*

YesNo
Have you used prescriptions for Hair Loss?*

YesNo
Have you had PRP treatments for Hair Loss?*

Yes:No:
What Hair Loss products have you used?*
Please indicate where hair loss bothers you the most*

Going outdoors on a windy daySocial LifeSeeing photo'sSwimmingPeople make commentsPeople make commentsAppearance at workOverall appearanceSeeing old friends
Consent for treatment: During the evaluation and recheck appointments, digital pictures and microscopicpictures will be taken and stored in a personal file for which i give my consent.*

I give my consent to use digital pictures on social media with my face ____.I give my consent to use digital pictures on social media with my face
I understand it is my responsibility to communicate with my medical provider before adding any supplements with current medications. I understand that Kerri’s recommendations should not be a substitute for medical advice by my 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 & Dr. of any changes in my condition, no matter how slight.

I understand that if I need to cancel or reschedule my appointment, a 24 hour notice must be given by text, phone call or via online booking reminders. I understand that there will be no fee if I cancel 24 hours of my scheduled appointment.
If for any reason I do not cancel or reschedule my appointment I understand that I will be charged 50% of my scheduled service total and may not reschedule until that fee is paid.
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