Hair Loss & Scalp Consultation

Name

Phone

Format: (000) 000-0000.

Email

example@example.com

Address

Age

Birthdate

Date

Preferred Way of Communication

How did you hear about me?

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

Other

Areas of hair loss

Do you have any hair loss on the body?

If yes what areas ?

Since onset, has it gotten: ?

Is your Hair:

Is your scalp:

Do you have an itchy or tingly scalp?

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?

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?

What kind of shampoo/conditioner do you use?

Do you use a hair dryer?

Setting level

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?

Have you had any of the following

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?

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?

Other

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?

Other

Have you had a hysterectomy?

Have you seen a dermatologist for your hair loss?

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)

Do you have any of the following:

Are you currently undergoing any radiation or chemotherapy?

Have you had radiation or chemotherapy in the past? If yes, please give the year.

Are you currently pregnant or nursing?

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?

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

Have you ever used oral or topical Minoxidil?

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

What are your goals and expectations?

Other

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 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.

Signature

Date

Hair Loss & Scalp Disorder Confidential Questionnaire