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Hair Loss Questionnaire

Birthday
Year
Month
Day
Have you experienced hair loss before?
Yes
No
Do you have any medical conditions? (Check all that apply)
Are you currently taking any medications?
Yes
No
Have you had any surgeries or treatments related to your hair or scalp?
Yes
No
Do you have any known allergies?
Yes
No
What type of hair loss are you experiencing? (Check all that apply)
Do you notice any changes in your scalp condition? (Check all that apply)
Have you tried any treatments for your hair loss?
Yes
No
Do you have any family members who suffer from hair loss?
Yes
No
Unsure
How would you describe your general stress levels?
Low
Moderate
High
Extremely High
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you have a balanced diet?
Yes
No
How often do you wash your hair?
Do you use any styling tools or chemicals on your hair?
Yes
No
What are your main goals regarding hair loss treatment? (Check all that apply)
How soon would you like to see results?
1-3 months
3-6 months
6 months or more
Are you open to exploring different treatment options (e.g., topical treatments, dietary changes, lifestyle modifications, professional procedures)?
Yes
No
Have you had any previous experiences with trichological treatments?
Yes
No

Consent and Acknowledgement

I hereby consent to an examination of my hair and scalp and understand that this consultation may involve a physical examination, potential treatments, and the collection of medical information.


I understand that the recommendations made by the hair artist are based on the information provided, and it is my responsibility to follow any guidance and instructions provided to me.

 

I acknowledge that the hair artist may refer me to medical professionals if necessary and that any treatments or products recommended are at my own discretion.

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