Hair & Scalp Solutions Consultation Form

Hair loss and changes in your hair can feel deeply personal. This form helps Melissa learn more about what you are experiencing, your hair and scalp history, and the type of support you may be looking for.

You do not need to know which assessment, treatment, or hair solution is right for you. Please answer as honestly and completely as possible. Melissa will review your information and guide you toward the most appropriate place to begin.

If you are interested in IBE extensions for length or volume and are not experiencing hair loss, please complete the separate IBE Consultation Form.

Name

First Name

Last Name

example@example.com

Phone Number

Please enter a valid phone number.

Which concerns or solutions are you interested in exploring?Select all that apply

Understanding why my hair is shedding or thinning

Hair and scalp assessment

Scalp discomfort or imbalance

Hair-restoration treatments

Epigenetic Hair Testing

Functional blood testing

A topper

A wig

CNC Hair Prosthetic System

I am unsure and would like Melissa’s guidance

Other

What is your main reason for reaching out?

What would you most like help achieving?Select all that apply

Understanding what may be contributing to my hair concerns

Reducing excessive shedding

Improving the condition of my scalp

Supporting healthier-looking natural hair

Covering thinning around my part or crown

Achieving full coverage

Finding a secure, continuously worn hair solution

Feeling more confident in my hair

Other

How soon are you hoping to begin?

As soon as possible

Within the next month

Within the next three months

I am gathering information for the future

I am unsure

What changes have you noticed?Select all that apply

More shedding than usual

Gradual thinning

Sudden hair loss

A widening part

Reduced density

A thinner ponytail

Receding around the hairline or temples

Patchy areas of hair loss

Visible scalp

Hair Breakage

Hair that feels weaker or more fragile

Changes in texture

Scalp itching or sensitivity

Excessive oil

Dryness or flaking

Buildup

Redness or irritation

Pain, tenderness, burning, sores, or lesions

Other

When did you first notice these changes?

Within the last three months

Three to six months ago

Six months to one year ago

One to three years ago

More than three years ago

Where are you noticing the most change?Select all that apply

Hairline

Temples

Part

Crown

Sides

Back of the head

Throughout the entire scalp

One or more isolated patches

Other

Has your hair concern remained the same, improved, or worsened?

It has become worse

It has remained about the same

It has improved

It changes over time

I am unsure

Please describe what you have noticed and how it has changed over time.

How is this affecting you emotionally or in your everyday life?

Have you experienced any of the following within the past two years?Select all that apply

Pregnancy or childbirth

Menopause or perimenopause

Starting, stopping, or changing birth control

Other hormonal changes

Significant illness or infection

Surgery or hospitalization

High fever

Covid-19

Rapid or significant weight loss

Major dietary changes

Increased emotional stress

A traumatic event

Chemotherapy or radiation

A new medical diagnosis

A new medication or dosage change

None of the above

Other

Do you currently have, or have you previously been diagnosed with, any of the following?

Thyroid condition

Anemia or low iron

Vitamin D deficiency

Hormonal imbalance

Polycystic ovary syndrome

Autoimmune condition

Diabetes or insulin resistance

Alopecia

Scalp condition

Skin condition affecting the scalp

Nutritional deficiency

Cancer

Other medical condition

None that I am aware of

If applicable, please provide any details you believe may be relevant.

Are you currently pregnant, breastfeeding, undergoing cancer treatment, or receiving care for a serious medical condition?

YESNO

If yes, please explain anything Melissa should know before recommending services.

Are you currently under the care of a healthcare professional for your hair loss or a related concern?

YESNO

If yes, what type of healthcare professional are you working with?

Primary care provider

Dermatologist

Endocrinologist

Gynecologist

Oncologist

Nutrition professional

Other

Please describe any guidance, diagnosis, testing, or treatment you have received.

Please list your current medications and supplements.Include prescription medications, over-the-counter medications, vitamins, supplements, and hormonal medications.

Do you have any known allergies or sensitivities?

YESNO

If yes, please list them.

Have you had bloodwork completed within the past 12 months?

YESNO

If yes, were any concerns identified involving thyroid function, ferritin, iron, vitamin D, hormones, or nutrition?

Would you be willing to provide recent bloodwork or discuss additional testing with an appropriate healthcare provider if Melissa believes it may be helpful?

Yes

I would like more information first

How would you describe your current stress level?

1: Very Low

3: Moderate

5: Very High

How would you describe your typical nutrition?

Are you currently following a restricted diet or experiencing difficulty consuming enough calories, protein, vitamins, or minerals?

YESNO

If there have been any significant changes in your weight, nutrition, or appetite, please explain.

How often do you wash your hair?

Daily

Every other day

Two to three times per week

Once per week

Less than once per week

Which scalp concerns are you currently experiencing?Select all that apply

Excessive oil

Dryness

Flaking

Buildup

Itching

Redness

Sensitivity

Tenderness or pain

Burning

Sores, lesions, or open areas

None

Other

What products or treatments are you currently using for your hair or scalp?Please include shampoos, conditioners, oils, serums, supplements, minoxidil, prescription products, laser devices, or other treatments.

What have you already tried for your hair concerns?Select all that apply

Hair-growth shampoo or scalp products

Vitamins or supplements

Minoxidil

Prescription treatment

Laser cap or light therapy

Microneedling

PRP or a similar treatment

Scalp treatments

Extensions

Toppers

Wigs

CNC or another attached hair system

Dietary or lifestyle changes

I have not tried anything

Other

Did you notice any improvement, irritation, or unwanted effects from what you tried?

Have you ever received a professional diagnosis related to hair loss?

YESNO

If yes, what diagnosis were you given, and by whom?

Please describe your natural hair.Select all that apply

Fine

Medium

Coarse

Straight

Wavy

Curly

Coily

Low Density

Medium Density

High Density

Unsure

What chemical services have you received within the past two years?Select all the apply

Permanent color

Highlights or lightening

Keratin or smoothing treatment

Chemical straightening or relaxing

Perm

None

Other

Have you experienced hair damage or breakage from color, heat, extensions, or another service?

YESNO

If yes, please explain

Do you currently wear hair extensions?

YESNO

Which extension method do you currently wear?

IBE

Another hand-tied method

Tape-In

Keratin or bonded

Clip-In

Unsure

Other

When was your most recent installation or maintenance appointment?

Who currently maintains your extensions?

Have you worn extensions in the past?

YESNO

If yes, which method did you wear, and what was your experience?

Have you experienced discomfort, breakage, scalp irritation, matting, or additional thinning while wearing extensions?

YESNO

If yes, please explain

What level of maintenance feels realistic for you?

Minimal at-home maintenance

Regular at-home care

Professional maintenance every several weeks

I am open to whatever my recommended solution requires

I am unsure

Are you interested in combining hair or scalp treatment with an immediate coverage solution?

Yes

I am unsure

I would like Melissa's Recommendation

Do you have a budget or investment range you would like Melissa to consider?

Is there anything that may prevent you from moving forward with a recommended plan?Select all that apply

Cost

Time commitment

Travel

Maintenance requirements

Medical Concerns

Fear or uncertainty

I need to discuss it with someone

Nothing at this time

Other

Please upload the following photos in natural lighting with no filters:Front view Back view Left side Right side Top of the head and part Any specific area of concern

What would make you feel that your consultation was successful?

What is your biggest question or concern for Melissa?

Is there anything else you would like Melissa to know before reviewing your form?