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eastgate towne center | 5600 brainerd road, ste. b8 chattanooga, tn 37411 | salon: 423.510.0883 | mobile: 423.593.4146 CONFIDENTIAL CONSULTATION QUESTIONNAIRE Name: ________________________________________________Date:________________________ Address: ___________________________________________________________________________ City: ___________________________________State:____________________Zip:_______________ Home Phone: ___________________________________Work Phone_________________________ DOB__________________Age:_____Occupation__________________________________________ E-Mail Address_____________________________________________________________________ Referred by: TV AD Internet Yellow Pages Google Salon Name: __________________________Other_________________________________________ MEDICAL HISTORY Allergies: ________________________________Are you allergic to shellfish? ___________________ General Health______________________________________________________________________ Previous Surgery with General Anesthesia________________________________________________ Do you have any of the following medical problems? Stroke Congestive Heart Failure Coronary Artery Disease Endocrine Disorders Irregular Heart Beat Anemia Depression Diabetes Liver Disease Hypertension Thyroid Disease Resaca Presently Undergoing Medical Treatment for______________________________________________ Physician’s Name: __________________________________Date of last physical_________________ Stress: High___________ Medium____________ Low_______________ Blood work: Have you had any of these tests done in the past year? CBC w/Diff Ferritin/Iron test Hormone: DHEA/Testosterone Thyroid Panel Glucose Tolerance eastgate towne center | 5600 brainerd road, ste. b8 chattanooga, tn 37411 | salon: 423.510.0883 | mobile: 423.593.4146 Condition of Hair and Scalp Is your Scalp: Dry Oily Any Redness or Itchy Scalp: Yes No Any Bumps or raised areas: Yes No Recurrent attacks of patchy hair loss: Areas of hair loss: All over scalp Any hair loss on body? Yes Yes Normal Do you pull your hair? Yes No No Hair of different lengths Yes No Front No Dandruff Crown What area?__________________________________________ At what age did you notice hair loss? _____ Was loss sudden? __________or Gradual? _______ Is your hair loss getting worse? ______If yes, can you collect in plastic bag daily? ____________ What kind of shampoo do you use? _____________Conditioner? ____________Co-Wash? ___________ How many times per week do you shampoo? _______ What type of hair dryer do you use? ___________________What temperature? Hot Do you towel dry your hair when wet? Is your hair color treated? Yes No Yes Medium Cool No How often? _______________________________ Is your hair loss concern caused by any medical problems or medications that you are aware of? __________________________________________________________________________________ HEREDITY Does hair loss run in your family? Yes___No___ Parents Grand P Siblings Aunt Uncles Bald Thinning Hair Not Bald Unknown eastgate towne center | 5600 brainerd road, ste. b8 chattanooga, tn 37411 | salon: 423.510.0883 | mobile: 423.593.4146 What options have you researched for your hair loss (including over the counter and prescriptions)? Transplants Scalp Treatments Over the counter products Other____________________ Hair Replacements or weaves Prescription products Avacor Minoxidil_____% Clubs or Hair Loss Clinics________________ Medications: Please list name of medication and dosage Anti-coagulants_______________________ Anti-Hypertensive________________________________ Hormones_______________Thyroid____________-Asprin__________Multivitamins_______________ Radiation Therapy_________________________Chemotherapy_____________Dialysis_____________ List any other medications______________________________________________________________ ____________________________________________________________________________________ Females Only Female Issues: Yes No Post Menopausal: Yes No Are you planning to get pregnant in the next 6 months? Yes No Are you currently pregnant or nursing? Yes No Do you take any type of Contraceptive? Yes Name_________________ No How long? ___________ Males Only Have you currently had or plan to take a PSA blood test for the screening of prostate cancer? Yes No Do you have an enlarged prostate or prostate cancer? Yes No eastgate towne center | 5600 brainerd road, ste. b8 chattanooga, tn 37411 | salon: 423.510.0883 | mobile: 423.593.4146 Nutrition: Are you a vegetarian? Yes No How many servings of protein do you get daily?_____________ Fruit__________Veggies_________Caffeine__________Carbs___________Protein____________ Do you take minerals in any form? Yes No Multi-Vitamins Yes No Lost or gained weight recently? Yes No How much? _____________ List any other supplements that you take__________________________________________________. How much does your hair loss bother you? Slightly______Moderately________Highly________ Did you tell anyone you were coming here today? Yes No Would you consider using prescription topical and pills if you could get better results? (Keep in mind, prescription products in general increase the cost of the program). Yes____ No_____ What are your goals and expectations? To prevent further loss_________ Get hair back quickly_______ Gradually gain back some hair_______ Other________________________________________________ Knowing that treatment may take 6 months or more to show success, are you willing to wait that long? Yes No Please circle where hair loss bothers you the most? No variation in hair style Wearing hats when going out Seeing old friends Seeing old pictures/videos Social Life Overall self esteem Conscious of appearance at work Going outside on windy days Swimming or getting caught in the rain Participating in sports Meeting new people Comments that people make Around your mate
