Client Hair Loss Consultation Form

1
Todays Date
Date
Month
Day
Year
2
Name
First Name
Last Name
3
Phone Number
Please enter a valid phone number.
4
Email
example@example.com
5
Age
6
Occupation
7
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
8
Presently undergoing treatment forIf none type N/A
9
Do you have any of the following issues
Anemia
Congestive heart failure
Coronary artery disease
Depression
Diabetes
Endocrine disorders
Hypertension (High blood pressure)
Liver disease
Rosacea
Thyroid disease
Stroke
Irregular heartbeat
If none type N/A
10
What is your stress level?
High
Medium
Low
11
Are you presently undergoing treatment, if "Yes" check "Other" and enter what for
Yes
No
Other
12
Physicians Name
If none type N/A
13
Dermatologist Name
If none type N/A
14
Date of Last VisitChoose most recent date
Date
Month
Day
Year
15
Are you allergic to shellfish, list any other allergies
Yes
No
Other
16
Anticoagulants
If not applicable type N/A
17
Antihypertensive
If not applicable type N/A
18
Hormones
If not applicable type N/A
19
Thyroid
If not applicable type N/A
20
Aspirin
If not applicable type N/A
21
Multivitamins
If not applicable type N/A
22
Radiation Therapy
If not applicable type N/A
23
Chemotherapy
If not applicable type N/A
24
Please list any medication or supplements.
If not applicable type N/A
25
Post menopausal
Yes
No
26
Female issues
Yes
No
27
Are you planning to get pregnant in the next 6 months?
Yes
No
28
Do you use contraceptive pills?
Yes
No
29
If "Yes", how long have you been taking them?
If not applicable, type N/A
30
Have you currently had or plan to take a PSA blood test for the screening ot prostate cancer?
YESNO
31
Do you have an enlarged prostate, prostate cancer?
YESNO
32
Is your scalp...?
Oily
Dry
Normal
Dandruff
33
Any redness or itchy scalp?
YESNO
34
Do you pull your hair?
YESNO
35
Any bumps or raised areas?
YESNO
36
Any recurring attacks of patchy loss?
YESNO
37
Does your hair have different lengths?
YESNO
38
Areas of hair loss are
All over
Front
Crown
Back
None
39
At what age did you notice hair loss?
40
How was you hair loss?
Gradual
Sudden
41
Name the brand of shampoo you use
42
How many times per week do you shampoo your hair?
43
Name the brand of conditioner you use
44
Do you color your hair?
YESNO
45
If yes, how often do you color your hair?
46
When your hair is wet how do you dry your hair?
Hair Dryer
Rub Dry
Towel Dry
Air Dry
47
What temperature hair dryer do you use?
Hot
Medium
Low
48
Any loss of hair on your body?
YESNO
49
If Yes, what part of your body?
50
Is your hair loss concern caused by any medical problems or medications that you are aware of?
YESNO
51
Does hair loss run in your family?
YESNO
52
Who in your family (is/has) suffers from hair loss?
Grandparents
Parents
Siblings
Aunts
Uncles
Cousins
Unknown
53
What operations have you reached for your hair loss(Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacements & Weaves
Acacor
Prescription products
Over the counter products
Minoxidil (Enter % below)
Hair Loss Clinics
N/A
54
Percentage of Minoxidil
55
How much does hair loss bother you?
Slightly
Moderately
Highly
56
Where does hair loss bother you the most?
No variation in hairstyles
Seeing pictures/videos
Going outside on windy days
Wearing hats
Social Life
Swimming/getting caught in the rain
Overall self esteem
Participating in sports
Meeting new people
Overall appearance
People making comments
Conscious appearance at work
Seeing old friends
57
What are your hair goals?
Prevent further hair loss
Gradually gain back some hair
Gain back hair quickly
58
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?
YESNO
59
I agree to being evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced consultant. All other checkups are included with the cost of the program, which include monthly and/or quarterly digital and microscopic pictures, for which I give my consent. I further understand results will vary depending on a large number of factors. I acknowledge that it is my responsibility to the company of any changes in my condition, no matter how slight. I understand some general recommendations will be made based on the initial consultation.
YESNO
60
Signature
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61
Date of Signature
Date
Month
Day
Year
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