Trichology Intake Form
Please fill out the form below prior to your consultation. After scheduling your consultation on my booking site, come back here and submit this form before your appointment day.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Hair & Scalp History
How long have you been losing hair?
*
Any scalp concerns?
*
Shampoo Frequency
*
Daily
Weekly
Bi-weekly
Monthly
Longer than a month
Shampoo and conditioner you’re presently using?
*
Do you apply scalp products at home? If so, what are you using?
*
Do you use any chemicals in your hair currently? (Relaxer, hair color, perm, etc).
*
Have you employed the services of anyone to correct your hair loss?
*
Personal Information
Marital Status
*
Single
Married
Divorced or Widowed
Separated
Employment Environment
*
Clean
Average
Dirty
Number of dependents/children? And ages.
Family Hair Loss History
Select all who have lost hair.
Mother’s side
*
Grandfather
Uncles
Brothers
Mother
Father’s side
*
Grandfather
Uncles
Brothers
Father
Medical History
Have you undergone treatment for any of the following conditions?
*
Diabetes
Hypertension (high blood pressure)
Low blood pressure
Thyroid disease
Pituitary imbalance
Blood disorder
Seizure disorder
Silver fillings
Heart disease
Low blood sugar
Iron deficiency (anemia)
Autoimmune disease
Keloids (scar formation)
Body building steroids
Skin disorder
Other medical treatment (please specify below)
Other (if applicable).
Dates
Date of last physical exam?
*
Date of last x-ray?
Health & Lifestyle History
Select all that apply.
*
Worn a hair piece or wig
Had anesthesia
Had implants or lesions
Been pregnant
Lost or gained more than 15 pounds in the last year
Taken daily vitamins or supplements
Smoke cigarettes
Allergic to drugs or medicine
On a special diet
Had an organ removed
Had a recent surgery
Irregular bowel movements
Scalp injury
On any medication
On blood thinners
Balanced diet
Habits
Alcohol use
*
Never
Occasionally
Often
Tobacco use
*
Never
Occasionally
Often
Drugs
*
Never
Occasionally
Often
Caffeine (coffee, tea, soft drinks, etc)
*
Never
Occasionally
Often
Scalp Assessment
Is your scalp:
*
Oily
Dry
Itchy
Sore or tender
Red or inflamed
Women Only
Select all that apply.
Pregnant
Menopause
Normal menstrual cycles
Contraceptives (birth control)
Taking hormones
Hysterectomy
PCOS
Thank you for being patient filling out this form. Please submit this form below.
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