Serene Beauty & Wellness – Hair Loss & Scalp Health Consultation
Please complete this consultation questionnaire as thoroughly as possible. Your answers help us personalize your hair and scalp plan.
How should we refer to you?
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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Occupation
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Please Select
Internet Search
Social Media
Friend or Family
Advertisement
Other
Primary Concerns
Hair Loss Concerns
Excessive shedding
Thinning hair
Receding hairline
Widening part
Patchy hair loss
Breakage
Slow growth
Scalp irritation
Other
Onset Timeframe
<3 months
3–6 months
6–12 months
1+ years
Pattern
Gradual
Sudden
Cyclical/comes and goes
Progressively worsened
Areas Affected
Crown
Temples
Hairline
Part line
Sides
Nape
Diffuse/all over
Hair & Scalp History
Scalp Symptoms
Itching
Flaking/dandruff
Oily
Dry
Redness
Burning/tenderness
Bumps/sores
Other
Wash Frequency
Daily
Every other day
2–3x/week
Weekly
Hair Services in Last 12 Months
Hair color
Lightener/bleach
Chemical straightening
Perm
Extensions
Tight styles
Styling Habits
Heat styling
Blow drying
Air drying
Protective styles
Minimal styling
Medical History
Diagnoses Checklist
Thyroid disorder
PCOS
Autoimmune condition
Anemia/low iron
Hormonal imbalance
Diabetes/insulin resistance
Gut disorders (IBS/SIBO/celiac/reflux)
Skin conditions (psoriasis/eczema)
Anxiety/depression
Long COVID
Other
Recent illnesses/surgeries/hospitalizations in past 12 months
Yes
No
If yes, please provide details
Medications & Hormones
Current prescription medications
Include birth control, hormone therapy, acne meds, etc.
Started or stopped any medications in last year
Yes
No
If yes, please provide details
Which best describes you?
*
Female
Male
Non-binary
Prefer not to say
Are your cycles regular?
Yes
No
Currently
Pregnant
Postpartum
Perimenopausal
Menopausal
None of the above
Supplements & Topicals
Supplements
Multivitamin
Iron
Vitamin D
B-complex/Biotin
Zinc
Omega-3
Collagen
Hair-specific supplements
Herbal supplements
None
Hair growth products/treatments used
Minoxidil
Laser/red light therapy
PRP
Microneedling
Oils or serums
Other
Diet & Nutrition
Diet type
Omnivore
Pescatarian
Vegetarian
Vegan
Keto/Low-carb
Other
Meals per day
1
2
3
4+
Protein intake
Low
Moderate
High
Regular consumption
Dairy
Gluten
Sugar regularly
Caffeine daily
Alcohol
Alcohol consumption frequency
Known food sensitivities/intolerances
Yes
No
If yes, please list sensitivities/intolerances
Lifestyle & Stress
Stress level
Low
Moderate
High
Chronic
Major stressors in past 12 months
Work
Family
Financial
Health
Emotional trauma
Sleep deprivation
Other
Sleep per night
<5 hrs
5–6 hrs
7–8 hrs
8+ hrs
Exercise frequency
None
1–2x/week
3–4x/week
5+ x/week
Allergies & Sensitivities
Allergy/sensitivity types
Medications
Foods
Essential oils
Fragrances
Hair products
Environmental
Other
Details
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Family History
Family history of hair loss
Yes
No
If yes, who?
Mother
Father
Siblings
Grandparents
Other
Goals & Commitment
Goals
Reduce shedding
Improve density
Regrow hair
Improve scalp health
Prevent future loss
Other
Willing to commit
In-clinic treatments
Home care protocol
Nutrition & lifestyle support
Multi-month program
Photo + Case Study Release
Consent
I give permission for before/after photos to be taken.
Consent
I allow my results to be used anonymously for educational/marketing purposes (no name or identifying details).
This consultation does not provide a medical diagnosis and does not replace care from a licensed medical provider. If you have concerning symptoms, please consult your physician.
Signature
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Signature Date
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Month
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Date
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