Hair Loss Consultation Form

1
Name
First Name
Last Name
2
Email
example@example.com
3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number
Please enter a valid phone number.
5
Birthday
Date
Year
Month
Day
6
What is your occupation?
7
When did your hair loss start (approximately)?
8
Is your hair loss:
General
Patches
Both
Front
Crown
9
Where are you experiencing hair loss?
Scalp
Face
Both
10
Is your hair:
Thinning
Shedding
Both
11
Does your scalp itch?
No
Mild
Moderate
Severe
12
Is your scalp flaking?
YESNO
13
Was your hair loss:
Sudden
Gradual
14
Since the onset, has it gotten:
Better
Worse
Stayed the same
15
How often do you shampoo your hair?
16
Which of the following products do you use?Check all that apply
Dry Shampoo
Dry Conditioner
Gel/Mousse
Hair Spray
17
Do you use:
Hair Color
Relaxer/Keratin
Hot Rollers/Curling Iron/Flat Iron
Blow Dryer
18
Do you wear any of the following hairstyles?
Ponytail
Braids/Twists
Dreadlocks
Weaves
Extensions
Headbands
19
Do you pull your hair?
YESNO
20
Have you recently dramatically changed your diet?
YESNO
21
Are you a Vegetarian?
YESNO
22
Are you a Vegan?
YESNO
23
Do you see a rash on your scalp or face?
YESNO
24
Are you on any type of hormone treatment?
YESNO
25
If YES, what type and for approximately how long?
26
Are you using any prescribed or over the counter weight loss medication?
YESNO
27
If YES, please list.
28
What prescription and/or over the counter medications do you currently use?Please list all below.
Huge
Large
Normal
Small
Ok
Ok
29
What treatment are you currently using for hair loss (medications, Rogaine, vitamins, serums, shampoos, etc.)Please list all below.
Huge
Large
Normal
Small
Ok
Ok
30
What treatments have you previously tried and for how long?Please list all below.
Huge
Large
Normal
Small
Ok
Ok
31
Have you seen a Dermatologist, Trichologist or Physician concerning your hair loss?
YESNO
32
Are you pregnant?
YESNO
33
Are you using a hormonal birth control?
YESNO
34
If YES, what type and for approximately how long?
35
Or if you have recently stopped taking it, when did you stop?
36
If applicable, are your menstrual periods:Check all that apply.
Regular
Irregular
Light
Moderate
Heavy
37
Have you gone through menopause?
YESNO
38
If YES, at what age?
39
Any hair loss in men in your family?
YESNO
40
If YES, who?
41
Any hair loss in women in your family?
YESNO
42
If YES, who?
43
Please answer the following medical history questions. Do you have?Check all that apply.
Psoriasis
Seborrheic Dermatitis
Double Vision
Cystic Acne
Excessive Facial Hair
Polycystic
History of Autoimmune Disease
44
If YES, for Autoimmune Disease:Please list.
45
In the past 3-12 months, have you experienced any of the following?Check all that apply.
High Fever
Childbirth
Severe Infection
Flare of Chronic Illness
Over or Under Active Thyroid
Start or Stop Beta Blocker Medication
Start or Stop Hormone Treratment
Start or Stop Birth Control Pills
Severe Stress
Low Iron in Blood
Weight Loss
Covid or Covid Vacine
46
Are you a smoker?
YESNO
47
I understand that the services rendered are not a subsitute for medical care and any information provided to the professional is for educational purposes only and not diagnostically prescriptive in nature. This consultation form is used to evaluate your individual scalp needs. I will maintain the confidentiality of this information. I will not provide or sell this information. I may reach out with product-related information and questions.
48
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