Name
*
First Name
Last Name
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Date of Birth
MM
DD
YYYY
How do you identify your gender?
Do you have any past or current issues / concerns?
Are you currently pregnant or nursing?
Do you take any forms of contraceptive?
If yes, how long?
Are you post menopoausal?
Have you had a full or partial hysterectomy?
Are you taking any performance enhancing drugs?
Are you using any protein isolate?
If yes, which one?
Have you currently had a plan to take a PSA blood test for screening prostate cancer?
Do you have an enlarged prostate or prostate cancer?
Do you have any dietary restrictions?
Other
Protein
Fruit
Vegetables
Caffeine
Carbohydrates
Your height
Have you lost weight recently?
If yes, how much?
List any allergies
Are you allergic to shellfish?
Blood type
General health history
Any previous surgery with general anesthesia?
Do you have any of the following medical problems?
Other
Are you presently undergoing any medical treatment?
Physician's name
Date of last physical
MM
DD
YYYY
Agree or disagree
You consider yourself in great health?
You feel you have a high level of stress?
Do you have occupational or environmental exposure to chemicals/pollutants?
How many hours of sleep do you get per night?
Do you engage in regular exercise?
Have you had any of the following tests done in the past year?
Medications
Please list any additional medications or supplements you are taking on your own or over the counter
Is your scalp
Any redness or itchy scalp?
Any bumps or raised areas?
Recurrent attacks of patchy loss?
Do you pull your hair?
Areas of hair loss
Any hair loss on the face or body?
If yes, what area?
What age did you notice hair loss?
Was the loss sudden?
Is your hair loss getting worse?
How many hairs lost per day?
What kind of shampoo do you use?
What kind of conditioner do you use?
How many times per week do you shampoo?
Do you use a hair dryer?
What temperature?
When your hair is wet, do you use a towel to rub dry?
Do you use chemicals on your hair?
bleach, perms, hair color, relaxers, etc.
If yes, how often
Do you use hair extensions or weaves regularly?
sew-in, tape-in, crochet, etc.
If yes, how often?
Do you regularly plait or braid your hair?
dreadlocks, twist, box braids, etc.
Is your hair loss concern caused by any medical problems or medications that you are aware of?
Does hair loss run in your family?
Who in your family is experiencing hair loss?
What would be the best thing about having your hair back?
Have you researched or tried any of the following options for your hair loss?
including over the counter and prescriptions
Other
How much does your hair loss bother you?
Would you like to consider using prescription topicals and pills if you could get better results?
What are your goals and expectations?
Considering that hair care plans may take 6 months or longer to show results, are you willing to wait that long?
Please indicate where hair loss bothers you most:
Consent & Acknowledgments
Thank You for Completing Your Patient History Intake Form!
We appreciate you taking the time to provide this important information. Your responses will help us better understand your hair and scalp concerns, allowing us to tailor our recommendations to your specific needs. A specialist will review your details and discuss the best course of action with you during your consultation. If you have any additional questions or concerns before your appointment, please don’t hesitate to reach out. We look forward to helping you on your journey to healthier hair and scalp!
