Scalp Ritual: The Restoration Consultation

Scalp Ritual: The Hair Restoration Consult

Please complete the following form to help us understand your hair loss and scalp health concerns. This information is vital for accurate diagnosis and effective treatment planning.
General Information
Name

First NameLast Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Age
Occupation
Referred by

Physician or Medical ReferralGoogleSocial MediaFriend or Family ReferralBeauty ProfessionalReturning ClientOther
If other:
Medical History
How would you describe your general health status?

ExcellentGoodFairPoor
Do you have/ have you had any of the following?

Hypertension (High Blood Pressure)DiabetesThyroid Disorder (Hypothyroidism, Hyperthyroidism, Hashimoto's, Graves')Autoimmune Disease (Lupus, Alopecia Areata, Psoriasis, ect.)Polycystic Ovary Syndrome (PCOS)Anemia (Iron Deficiency, B12 Deficiency, ect.)Chronic Stress or AnxietyRecent Illness or Infection (COVID 19, Flu, ect.)Hormonal Imbalance (Estrogen, Testosterone, DHEA, ect.)None of the aboveOther
List any surgeries within the past two years?
Are you currently taking any prescribed or over-the-counter medications?
Do you take any nutritional supplements regularly? (E.g. biotin collagen, iron, vitamin D)
Allergies (Shellfish, ect.)
Overall stress level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Nutrition
Are you a vegetarian/ vegan?

YesNo
Are you eating protein daily?

YesNo
Have you gained or loss weight!*

YesNo
Are you on any GLP-1’s for weight loss or metabolic health*

YesNo
Lifestyle Factors
Do you smoke or vape?

YesNo
Average daily caffeine intake?
Female Clients
Are you pregnant or nursing?

PregnantNursingBothNeither
Have you experienced recent hormonal changes?

PostpartumPerimenopauseMenopausalIrregular menstral cyclesNone
Do you used or are you currently using birth control?

YesNo
If yes, please specify type and duration?
Are you planning to become pregnant within the next six months?
Have you ever taken hormone replacement therapy (HRT)?

YesNo
If yes, please specify?
Hair and Scalp Conditions
When did you first notice hair loss?
Describe the pattern of your hair loss:

Diffuse ThinningReceding HairlineBald PatchesOverall Shedding
Is your hair loss:

SuddenGradual
Do you experience any of the following scalp symptoms?

ItchingFlakingRednessTendernessItchyTingly sensationBurning sensation
Have you ever been diagnosed with any scalp conditions? (e.g. psoriasis, seborrheic dermatitis)
Have you ever had a scalp biopsy

YesNo
If yes, please provide details:
Do you pull or pick your hair

YesNo
Is your hair at significantly different lengths

YesNo
Are you experiencing hair loss on your body

YesNo
Do you have any indication or theory of where your hair loss of scalp condition may be from?
Hair Care Practices
How often do you shampoo your hair?
List hair care products currently in use:
Do you use any of the following hair treatments? (select all that apply)

Hair DyeRelaxersPermsHeat Styling ToolsHair ExtensionsTight Hairstyles (ponytails, brainds)
Have you ever experiences any adverse reactions to hair treatments?

YesNo
Do you blow dry your hair?

YesNo
Previous Hair Loss Treatments
Have you tried any hair loss treatments in the past?

Rogain/ MinoxidilFinasteride/ PropeciaPRPExosomes or Growth FactorsLow Level Laser Therapy (Laser cap)MicroneedlingWigs/ toppers/ extensionsTransplantSupplementationOther
If other, please specify:
If you tried treatments, did you notice any improvements?

YesNo
Please Describe:
How much does your hair loss bother you

1

2

3

4

5

6

7

8

9

10

1 is Slightly, 10 is Highly
Family History
Is there a family history of hair loss?

YesNo
If yes, please specify affected relatives:
Scalp Treatment Goals & Preferences
Did you tell anyone about starting your journey today?

YesNo
What are your primary goals for this treatment? (Select up to 3)

Slowing hair lossStimulating new hair growthImproving scalp healthReducing scalp irritation or inflammationStrengthening existing hairQuickly growing hair backDetoxifying scalp buildupLearning better scalp and hair care routines
Knowing that treatment may take 6 months or more to show success, are you willing to commit?

YesNo
Please indicate where hair loss bothers you the most:

No variation in hairstyleBeing outside on a windy daySocial lifeSeeing old friendsOverall apperanceConscious of apperance at workSeeing pictures/ videosWearing hats when going outSwimming or getting caught in the rainOverall self-esteemMeeting new peoplePeople making coments
Service Add on Options
Would you prefer

Low Level Laser Treatment, medical grade red light diodes to reduce inflammation, stimulate blood flow and cells proliferation to signal hair growth. ($30)
Consent and Policy Agreement
Do you consent for before and after pictures or treatment process pictures to be used for educational and/ or media purposes?

YesYes, but without my faceNo
By signing my name below I agree to be evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced Trichologist. I give my consent to have digital pictures and microscopic pictures taken and stored in a personal file. I further understand results will very depending on a large number of factors. I acknowledge that it is my responsibility to report any any changes in my condition, no matter how slight. I will communicate with my medical provider before adding any supplements with current medications. I understand that these recommendations should not be a substitute for medical advice by physician.
Signature

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Scalp Ritual: The Hair Restoration Consult

General Information

Medical History

Nutrition

Lifestyle Factors

Female Clients

Hair and Scalp Conditions

Hair Care Practices

Previous Hair Loss Treatments

Family History

Scalp Treatment Goals & Preferences

Service Add on Options

Consent and Policy Agreement