• Scalp RX Intake + Ingredient Label Upload

    Share your scalp concerns and upload clear ingredient label photos so we can tailor your Scalp RX assessment and home care plan.

  • Client Information

  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Client Age Confirmation / Parent or Guardian Contact (if under 18 or if needed)*

  • Primary Scalp Concern

  • What scalp concerns are you experiencing?*
  • Does it happen constantly or in flare-ups?
  • Which areas are affected?*

  • Symptom Details

  •
  • Do you scratch or pick at your scalp?*
  • Which of the following symptoms have you noticed?*

  • Known Diagnoses and Medical Care

  • Have you ever been diagnosed by a healthcare professional with any scalp, skin, hair loss, autoimmune, hormonal, or nutritional condition?*
  • Which diagnoses have you received?
  • Are you currently under the care of a dermatologist or other healthcare professional for this concern?
  • Scope note: The Loc Biologist does not diagnose medical conditions. Assessment findings may indicate the need for referral to a licensed healthcare professional.

  • Hair Loss and Shedding

  • Which hair loss or shedding patterns are you noticing?*
  • Where is the hair loss or shedding located?*
  • Did it start suddenly or gradually?*
  • Did you notice any possible trigger around the time it started?

  • Hormonal, Postpartum and Health History

  • Are you currently pregnant?
  • Are you currently postpartum or recently postpartum?
  • Are you currently breastfeeding or chestfeeding?
  • Are you perimenopausal or menopausal?
  • Have any of the following occurred recently?
  • Do you have a history of any of the following?

  • Medications and Supplements

  • Current medications and supplements
  • Were there any changes in your medications or supplements in the 6 months before your scalp or hair concern began?*

  • Wash, Sweat and Styling Habits

  • Do you usually let sweat dry on your scalp before cleansing?
  • How often do you wear wigs, hats, bonnets, scarves, helmets, extensions, braids, or other protective styles?
  • Have you experienced tension or tenderness from styling?

  • Current Products and Ingredient Review

  • Current scalp and hair products*
  • Ingredient label photos
  • Upload a File
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  • Front label photos
  • Upload a File
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  • Have you recently started or stopped any scalp or hair products?
  • Any product seems to trigger symptoms or buildup?

  • Allergies and Sensitivities

  • Known allergies or sensitivities

  • Nutrition and Lifestyle

  •
  • Eating patterns*
  • Have you made any major dietary changes recently?
  • How often do you regularly include these foods?*
  • Do you use tobacco or nicotine products, if comfortable sharing?
  • Lifestyle check-in*
    Rows

  • Scalp and Hair Photos

  • Front hairline photo*
  • Left side photo*
  • Right side photo*
  • Crown or top photo*
  • Back or nape photo*
  • Close-up photo of area(s) of concern*

  • Goals and Expectations

  • What are you seeking support with?*

  • Consent and Scope Acknowledgement

  • Acknowledgement of scope and limitations*
  • Consent to scalp photography and microscope imaging for charting*
  • Educational or marketing image use consent
  • Acknowledgement of medical referral guidance*

  • Signature

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: