Confidential Hair and Scalp Questionnaire

Client Details:

Certain occupations can increase exposure to toxins or elevate stress levels, both of which may impact overall health and hair wellness.

For example:

•  Chemical exposure is common among graphic artists, using dyes or pigments auto mechanics and body repair professionals working with paint and solvent hairstylist handling, chemical products and even office workers regularly exposed to copier toner.
• High-Stress careers such as law, medical, sales, law-enforcement, and full-time students can also contribute to imbalances in the body that affect the scalp and hair.

Understanding your lifestyle and environment is an important step in addressing the root causes of hair and scalp concerns.

Recent surgeries, especially those involving general anesthesia, can trigger temporary hair shedding due to physical stress on the body. It's also important to know if a woman has had a hysterectomy, as this can cause significant hormonal shifts – even for those on hormone replacement therapy.

Let's Start Putting The Pieces Together

your answers to these health – related questions will help us uncover potential root causes and provide a clearer picture of what may be contributing to your hair or scalp concerns.

Medical Conditions That May Impact Hair Loss and Treatment Options

Certain health conditions can contribute to hair loss or influence how the body responds to treatment. It’s important to understand these factors to ensure a safe and effective approach:

• Cardiac Conditions
  Individuals with congestive heart failure, irregular heartbeat, or coronary artery disease may require clearance from their cardiologist before starting certain treatments—especially those involving high-strength minoxidil.
  (Minoxidil was originally developed to lower blood pressure and later discovered to promote hair growth. It is a linear-dose medication, meaning higher strengths often deliver greater results—but with increased cardiovascular considerations.)
• Anemia & Thyroid Disorders
  Both hypothyroidism and hyperthyroidism, as well as iron deficiency anemia, are common underlying causes of hair thinning and loss.
• Diabetes
  Poorly managed diabetes can lead to delayed healing, impaired circulation, and contribute to scalp health issues.
• Depression & Liver Disease
  These conditions affect overall wellness, and the medications used to manage them may trigger or exacerbate hair loss.
• Stress
  Chronic stress, especially in women, is a major contributor to hair loss and may lead to telogen effluvium—a condition that can take up to 16 weeks to begin reversing, even with treatment.

Please Note – clients should never stop medication's without consulting their doctor!

Many medications may cause hair loss as a side effect. Most common are Anticoagulant such as Heparin, Warfarin (Coumadin), Anti-Depressants, Hormones, Birth Control, as well as HRT, some thyroid medications, and statins (cholesterol lowering drugs.)

FEMALES ONLY

Males Only

*If you are currently being monitored for prostate health, undergoing PSA testing, or have a history of an enlarged prostate, please consult with your physician before starting any supplement containing saw palmetto.

Saw Palmetto, a natural DHT (dihydrotestosterone) blocker that may support hair growth – but it can also affect prostate health markers.

Diet and Nutrition

Nutrition & Hair Health: What You Need To Know

 Your diet plays a vital role in maintaining healthy hair. Here are some important guidelines to consider:

 Protein intake

 Adequate protein is essential for hair growth. The general guideline is 0.8 g of protein per kilogram of body weight (1 kg kilogram equals 2.2 lbs.)

✳️ Note: Individuals with kidney disease or those on protein, restricted diet should follow medical guidance.

Vegetarian and Vegan Diets

Hair relies on complete proteins (those containing all essential amino acids), which are primarily found in animal-based sources like meat, fish, poultry, dairy, and eggs.
Plant-based proteins—such as nuts, legumes, and soy—are incomplete, and without careful planning, vegetarians may struggle to meet the body’s protein needs for optimal hair health.

Fruits & Vegetables
A diverse, colorful variety of fruits and vegetables provides essential vitamins, minerals, and antioxidants that support scalp health and cellular repair.

Caffeine Intake
Excessive caffeine consumption (from coffee, tea, sodas, energy drinks, or even chocolate) can interfere with B-vitamin absorption, which plays a crucial role in hair growth. Moderation is key.

Rapid Weight Loss
Significant or rapid weight loss—whether through dieting, gastric bypass, or bariatric surgery—can lead to temporary hair shedding due to the physical stress placed on the body and nutrient depletion.

Hair and Scalp Condition(s):

Scalp Observations & Considerations

During your consultation, visible scalp conditions can provide helpful insights into your overall scalp and hair health.

 Flaking or dandruff may indicate dryness, sensitivity, or an allergic response.
Redness, bumps, raised areas, or itching can be signs of infection (bacterial or fungal), insect bites, or more serious concerns like skin cancer.
Scaly or raised patches, especially white and thickened, may suggest conditions such as psoriasis.

Open wounds, cuts, or rashes should be evaluated by a physician or dermatologist before beginning treatment.

 Chemical damage (from harsh treatments or perms) or physical trauma (burns, accidents) may result in scarring that prevents regrowth.

 Some clients may experience hair loss related to Trichotillomania — a hair-pulling behavior affecting the scalp, eyebrows, or lashes. Professional counseling may help manage this condition, as repeated pulling can cause permanent hair loss.

 It’s normal to shed 50–100 hairs per day, and about 10% of your hair is naturally in a shedding phase at any time. However, excessive shedding — especially noticeable on pillows, clothing, or in the shower — may signal an imbalance and warrant deeper investigation.

 Alopecia areata presents as sudden, patchy hair loss, and may affect the scalp, eyebrows, or beard. It’s often linked to autoimmune activity or high stress. Severe forms include alopecia totalis (loss of all scalp hair) and alopecia universalis (loss of all body hair). Medical evaluation is recommended to rule out underlying autoimmune disease, such as lupus.

 Scarring alopecia can appear as red, inflamed patches that heal into smooth, bald areas with no follicular activity. These areas are often permanent and diagnosed via biopsy, though surrounding hair can sometimes be strengthened and blended for coverage.

 Lastly, the type of shampoo you use matters. Avoiding ingredients like Sodium Laureth Sulfate (SLS) and DEA may help reduce irritation. These chemicals are often used for their lathering effects but can contribute to scalp inflammation or, in rare cases, long-term concerns when combined with other ingredients.

 🔎 Disclaimer: I am not a physician.

While I specialize in scalp and hair wellness, I do not diagnose medical conditions. If anything observed or discussed during your consultation suggests a possible underlying medical issue, I will recommend that you consult with your primary care provider or a dermatologist for further evaluation and care.

My role is to support your overall scalp and hair health through holistic, non-medical services and education. Your safety and well-being are always my top priority.

Longevity of Hair Loss 

* Hair may be damaged with excessive heat, using irons and blow dryers.

– Wet hair is more vulnerable and thinner, weak hair may be damaged when vigorously rubbed.

Just a note about family history :

If you're unsure whether your hair loss runs in your family, it can help to think beyond just your parents. Hair loss can skip generations and be passed down through multiples, so it may show up in unexpected ways – even if no one close to you has experienced it. Let's explore what you know, and I'll help connect the dots.

Client Consent & Acknowledgment

I agree to participate in a comprehensive initial evaluation focused on scalp and hair health, conducted by a trained practitioner. I understand that this evaluation is not a medical diagnosis, but a wellness-based assessment to help guide my personalized care.

 As part of ongoing support, I give my consent for periodic scalp imaging (including digital and microscopic photos), which may be taken monthly and/or quarterly to monitor progress. These check-ins are included as part of my treatment plan.

 I understand that individual results may vary due to a variety of factors, including personal health history, lifestyle, and consistency with recommended care. I acknowledge that it is my responsibility to inform my practitioner of any changes in my health or condition, no matter how small, as they may affect treatment outcomes.

 I understand that general recommendations will be provided following the initial consultation, and that referrals to outside professionals may be suggested if concerns arise that fall outside the scope of this practice.