Client Intake Form

Client Intake Form

Please fill out the following information to help us understand your medical background.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Occupation *
Some occupations expose people to toxic chemicals: graphic artis working with dyes or pigments, auto mechanics / auto body repair who work with paints or solvents, hair stylist, office workers who are exposed to toner from copiers, etc. Or have high stress level: lawyers, sales, police, medical personnel, and students.
Referred By:
Allergies
Are you allergic to shellfish?*
Previous Surgery(s) with General Anesthesia
Previous Surgery with General Anesthesia: (Especially recent surgery as general anesthesia or the stress of the surgery may cause a shed. Important to know if a woman has had a hysterectomy which will cause some hormonal shift even if she is on hormone replacement therapy
Let's connect the dots...

Answering all of our health-related questions will help ensure that we eliminate or pinpoint what might be going on.

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Do you have any of the following issues? Check all that apply.

Congestive Heart FailureCoronary Artery DiseaseCoronary Artery DiseaseThyroid Disease (hypothyroidism and hyperthyroidism)AnemiaDiabetesDepressionLiver DiseaseStrokeIrregular heartbeatRosaceaEndocrine DisordersOther
-Congestive heart failure, Irregular heartbeat, Coronary Artery disease are all cardiac issues that may require permission from their cardiologist before treatment, especially if they are going to use a higher strength minoxidil.

*Minoxidil was originally used to lower blood pressure, and as a side effect was found to help hair growth. It is a linear dose drug SO the higher the strength, the better it works.

-Anemia and Thyroid disease (hypothyroid and hyperthyroid) may cause hair loss.

-Diabetes - diabetics usually take longer to heal and if not controlled, may also cause poor circulation.

-Depression and liver disease effect general health and medications given to treat these conditions may cause hair loss.

-Stress is a big factor in hair loss, especially for women and may cause telogen effluvium. This condition even with treatment may take up to 16 weeks to reverse.
Presently undergoing treatment for
Physician's Name
Please list medication(s) name(s) and dosage(s)
Date of last physical

MonthDayYear
Date
Anticoagulants
Hormones
Thyroid
Aspirin
Multivitamins
Radiation Therapy
Chemotherapy
Over-the-Counter Medicines and Supplements
PLEASE NOTE- CLIENTS SHOULD NEVER STOP MEDICATIONS WITHOUT CONSULTING THEIR DOCTOR!

Many medications may cause hair loss as a side effect. Most common are anti-coagulants such as heparin, warfarin (Coumadin), Anti-depressants, hormones (birth control as well as HRT), some thyroid medications, and statins (cholesterol lowering drugs).
Females Only

______________________________________________________________________
Are you planning to get pregnant in the next 6 months?

YesNoCurrently on birth controlCan't get pregnant
Are you currently pregnant or nursing?

YesNo
Do you take contraceptive pills?

YesNo
How long have you taken them?
Males Only

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Have you currently had or plan to take PSA blood test for the screening of Prostate Cancer?

YesNo
Do you have an enlarged prostate or prostate cancer?

YesNo
Men who have enlarged prostate or are being checked (PSA) for enlarged prostate, need to let their doctor know they are taking an "anti-androgen" saw palmetto (XTC's Supplements) or PropeciaTM/Finasteride as they may cause the PSA to have lower value than it really is.

The doctor may suggest he discontinue taking the supplement for a week or two, prior to having this test performed for a more accurate reading of their level.
Diet and Nutrition

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Diet is particularly important for healthy hair. An adequate protein intake is essential.

How much a person needs per day is based on body weight at .8g per kilogram (2.2lbs).

The only contraindication on this is a person who needs to restrict protein intake such as someone with kidney disease.

-Vegetarians who do not eat any kind of animal protein will have a difficult time with adequate protein as there are two types of protein- complete (animal based such as meat, fish, and poultry which includes dairy products and eggs) and incomplete (nuts, legumes, soy, etc)

-Fruits and vegetables are important, and people should eat a variety of colors for the best nutritional value.

-Caffeine (coffee, tea, colas, chocolate, energy drinks) interferes with how your body processes B vitamins SO excessive use should be avoided.

-Anyone who has lost a lot of weight in a short period of time (diet, gastric bypass, or bariatric surgery) will lose hair.
Are you on any diet plans?

KetoGluten FreeWeight Loss RegimenVegetarianNothing AbnormalFastingOther
Daily Servings of Protein
Daily Servings of Fruits
Daily Servings of Vegetables
Daily Servings of Caffeine
Daily Servings of Carbohydrates
If you have lost weight recently, how much and how fast?
Hair and Scalp Conditions

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Is your scalp...

DryOilyNormal
Any redness or itchy scalp?

YesNoOther
Do you pull your hair?

YesNo
Any bumps or raised areas?

YesNo
Recurrent attacks of patchy loss?

YesNo
Hair of different lengths?

YesNoOther
What area?
At what age did you first begin noticing hair loss?
Hair Loss Facts

-Some of this information you will notice when you examine the scalp. Dandruff may be a sign of an allergic reaction or an excessively dry scalp.

-Redness, bumps, raised areas or itching may be a sign of an infection (bacterial or fungal) as well as insect bites or more serious problems such as melanoma.

-Any raised rash, scaly areas (raised white scaly areas may be psoriasis) or open cuts/wounds should be referred to their physician or a dermatologist.

There may also be chemical (perms, strong chemicals) or physical scaring (heat, accident) where regrowth may not be possible.

Occasionally a person with Trichotillomania will come for treatment. These people pull out their hair, eyebrows, eyelashes and may benefit from counseling to find out the cause of this abusive type of behavior. If they continue to pull out their hair, the loss may become permanent

Normally approximately 10% of the hair is in the growth stage and a person may lose 50 to 100 hairs per day.

It is when people see hair all over their pillow, sink and clothes that there is real concern, and they seek treatment. People like animals, do occasionally shed and is not cause for alarm as long as they are replacing those hairs which would be visible with the capilloscope.

What kind of shampoo do you use? Shampoos without sodium laureth sulfate (SLS) or DEA are safer and healthier. SLS may cause irritation and DEA when it sits on the shelf in a cosmetic product may react with other ingredients to form a potent carcinogen called nitrosodiethanolamide (NDEA).

These ingredients are added to shampoo because they emulsify the product and provide a rich lather that people think necessary to have "clean" hair.

Patchy areas on scalp, eyebrow, facial hair (men), may be alopecia areata. This is usually a sudden hair loss that may progress to Totalis (all the scalp hair) or universalis (all body hair. It is thought to be an auto immune disease and usually happens to someone under increased stress. It may only be an allergic reaction, but the cause is not really understood. Hair loss may be a symptom of a disease such as lupus and / usually recommend that people with alopecia areata see their doctor to rule out a serious auto immune disease.

Another cause of patchy loss would be scaring alopecia. This is usually seen as a red area that may have some drainage. When it heals, it is very smooth with no hair. A diagnosis of scaring alopecia is usually done by biopsy of the area by a dermatologist. There are no follicles in the scarred areas and regrowth is not possible. The hairs around these areas may be strengthened with treatment and may make these areas easier to hide with other hair.
Longevity of Hair Loss

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Can you explain in your own words how your hair loss has made you feel?
Is your hair loss getting worse?

YesNoOther
What kind of shampoo do you use?
What kind of conditioner do you use?
When your hair is wet, do you rub it dry?

YesNoOther
When your hair is wet, do you blow your hair dry?

YesNoOther
How many times per week do you shampoo?
How often do you color your hair?
Heredity

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Does hair loss run in your family?

YesNo
Any balding or thinning hair in any of these family members? Check all that apply.

ParentsGrandparentsSiblingsAunts/Uncles
What Products have you looked into or tried in the past?

SMPXTCHLCCBosleyHair ClubKeepsHims/HersKeraniqueOther
What options have you researched for your hair loss (Including over the counter and prescriptions
Please select all that apply.
If you have tried anything else for hair loss, can you please list them below.
Please indicate where hair loss bothers you the most.

No variation in styleGoing outside on windy daysPhotos/VideosWearing hats when going outSwimming or getting caught in the rainOverall appearance and low self esteemSocial lifeSeeing old friendsParticipating in sportsMeeting new friendsPeople making comments
What are your long-term goals and expectations with working with a Trichologist?
Knowing that treatment options may take 6 months or more to show success, are you willing to wait that long?
Please select all that apply.
I agree to be evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced consultant. All other checkups are included with the program's cost, which includes monthly and/or quarterly digital and microscopic pictures, for which I give my consent. I further understand results will vary depending on a large number of factors. I acknowledge that it is my responsibility to the company for any changes in my condition, no matter how slight. I understand some general recommendations will be made based on the initial consultation.
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