Health Assessment

What age did you notice the hairloss

Is your hair loss getting worse

What is your current brand of Shampoo/Conditioner

How often do you shampoo

Hair Dryer Temp

Hot Medium Cool Towel Dry

Is your color permanent or rinse

Has your hair been overprocessed to your knowledge

Do you feel your hair loss is due to

Neglect Unprofessional care color chemicals Unknown

Is your current hair care with a professional or at home care *

Professional Stylist name/number(if you would like them to be notified of your recommended treatment)

Does Hair Loss run in your family *

Parents (Mom/Dad) Maternal Grandparents Paternal Grandparents Siblings Aunts Uncles

Other hair loss options I have already tried

Medical Conditions *

Last Physical

Last X-Ray

Females Only

Pre-Menopause Menopause Post-Menopause Planning to get pregnant Currently nursing Oral contraceptives

Males Only

PSA screening Enlarged prostate Prostate Cancer

I am presently undergoing treatment for

Please list any additional information you feel we need to know about your hair

Primary care name/number

Endocrinologist name/number

Dermatologist name/number

If you were referred by Dermatologist, what is your diagnosis

Please list what you had for Breakfast, Lunch, Dinner, snacks and liquids yesterday *

I am being evaluated by Hair Loss Practioner Leia' Love of Leia' Love Hair Restoration LLC (LLHR LLC). I understand the success of my therapy depends 100% on my compliancy to follow recommended protocol suggestions. I understand it is my responsibility to inform LLHR LLC of any changes in my medical conditions. Missed therapy appointments will not be refunded or prorated. I understand I will incur $50 non-refundable cancellation fee unless cancelled within 48hrs.

Date

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