Hair Loss & Scalp Consultation

Hair Loss & Scalp Disorder Confidential Questionnaire
Name*
Phone*
Email*
example@example.com
Address*
Age
Birthdate*

MonthDayYear
Date
Preferred Way of Communication*

Video CallPhoneTextEmail
How did you hear about me?*

Current hairstyling guestFacebookInstagramGoogle searchOther
Friend or family referral:
Chief complaints: Describe in your own words your hair loss and/or scalp issues.: *
HISTORY OF HAIR AND SCALP HEALTH
When did your hair loss start? Include how many months/years ago you began noticing hair loss and at what age.*
Was the onset of hair loss*

SuddenGradualNoneOther
Areas of hair loss*

All over scalpFrontTop of the headSidesOther
Do you have any hair loss on the body?*

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

BetterWorseAttacks of Patchy LossesStayed the SameOther
Is your Hair:*

ThinningSheddingBothNone of the above
Is your scalp:*

Oily- need to wash daily or every other dayNormal- need to wash twice per weekDry- wash once per week or lessFlakyOther
Do you have an itchy or tingly scalp?*

Mild - sometimes itches or tinglesModerate- itches or tingles oftenSevere- itching and tingling constant and irritates me oftenScalp is sensitive to the touchCrawling sensationBurning sensationNoneOther
Many people have nervous habits that include hair pulling and twirling. Do you pull or twirl your hair or have been told you pull or twirl your hair without realizing it?*

YesNo
Does hair loss run in your family? Hair loss can be genetic and can include any biological family members including your mother/father, brother/sister, aunts/uncles and cousins. Please include any family members with hair loss issues.
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?*
When do you typically wash your hair?

MorningEveningBoth morning and evening
What kind of shampoo/conditioner do you use?*
Do you use a hair dryer?*

YesNo
Setting level*

HotMediumCool
Do you currently use a flat iron or curling iron? If yes, what temperature do you use it on?
Do you color your hair? Have you ever had a reaction to color?*

Yes I currently color my hair but have NOT had an allergic reaction to color in the pastYes I currently color my hair and I HAVE had an allergic reaction to color in the pastNo I do not currently color my hair
Have you had any of the following*

DreadlocksTight braidsHair ExtensionsGlued on WigNone
HEALTH HISTORY
Is your hair loss caused by any medical problems or medications that you are aware of?*
Many medicines can cause hair loss. Loss may be gradual or sudden and can occur immediately or after several months. Please list your current prescription and over the counter medications you are taking or have stopped taking in the last 6 months.*
Pease list by name any supplements or vitamins you started or stopped taking in the last 6 months.*
Do you have any food, medicine or environmental allergies?
Are you allergic to shellfish?

YesNo
How is your general health? Include any conditions, diseases, or auto-immune issues in the last three years.
Have you had any surgeries with general anesthesia in the past three years? Please list those surgeries and include the year.
Have you given birth or miscarried a pregnancy in the past three years? Please list any deliveries or miscarriages and include the year.
Have you recently changed your diet? If yes, please explain those changes.
Are you a vegetarian?*

YesNoOther
Have you recently lost weight and/or currently taking weight loss medications?
Are you on any type of hormone treatment? If yes, please explain.
Has a doctor diagnosed you as peri-menopausal or menopausal?*

Peri-menopausalMenopausalNoneOther
Have you had a hysterectomy?*

Partial hysterectomyFull hysterectomyNone
Have you seen a dermatologist for your hair loss?*

YesNo
Are you presently under going treatment from a dermatologist for if any condition?*
What is your occupation?
Rate your stress level: (1: LOW 5:HIGH)*

12345
Do you have any of the following:

Anemia: low ironSkin disorders: psoriasis, eczema, rosaceaDiabetesThyroid issues: hypothyroid or hyperthyroidLow blood pressureHigh blood pressureLiver diseaseEndocrine disordersOther
Are you currently undergoing any radiation or chemotherapy?

YesNo
Have you had radiation or chemotherapy in the past? If yes, please give the year.
Are you currently pregnant or nursing?

YesNo but actively trying to get pregnantNo and no plans to get pregnant
FOR MEN ONLY: Have you had a PSA test for the screening of prostate cancer? Do you have an enlarged prostate or prostate cancer?
Do you have any of the following issues with your hands?*

ColdRednessScalesNumbness or tinglingNoneOther
Do you have any of the following issues with your nails?*

BrittleYellowingNail bitingRidgesPeelingNoneOther
Have you ever used oral or topical Minoxidil?*

YesNo
Have you ever used any doctor prescribed medications for hair loss or a scalp condition? Include both topical and oral
What non-prescription hair loss or scalp condition products have you used? Include any topical and oral products. Include vitamins, serums, special shampoos, topical cleansers and treatments, and devices.*
Please indicate how your hair loss bothers you*

Social lifeSeeing photos of yourselfPeople make commentsOverall appearanceSelf-confidenceDifficulty stylingOther
What are your goals and expectations?

Prevent more hair lossGrow lost hair back quicklyGradually grow back lost hair and grow fuller hairOther
Consent for treatment: During the evaluation and re-check appointments, digital pictures and microscopic pictures will be taken and stored in a personal file for which i give my consent.*

I give my consent to use digital pictures on marketing materials with my faceI give my consent to use digital pictures on marketing materials showing my hair and scalp but NOT my faceI do not give my consent to use digital pictures on marketing materials but understand my photos will be stored privately to evaluate my progress
I understand it is my responsibility to communicate with my medical provider before taking any medications or supplements. I understand that these hair loss recommendations should not be a substitute for medical advice by my physician.

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 & medical provider of any changes in my condition, no matter how slight.
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Hair Loss & Scalp Disorder Confidential Questionnaire