Hair Loss Consultation Form (UK) | Aesthetics Forms Portal

Hair Loss Consultation

Client Details

Date:

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Do you have any medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Hair and Scalp

What is your natural hair colour? *

Is your hair artificially coloured? *

When did you first notice your hair loss? *

What first made you aware of your hair loss? Did your problem develop suddenly or gradually over time? *

Where does your problem exist? Please tick all that apply.

Frontal Area Top of Head / Crown Patchy All Over

Do you have any of the following scalp conditions? Please tick all that apply.

Do you have any of the following hair conditions? Please tick all that apply.

Texture Change Manageability Frizziness Wave Pattern Change Patchy Loss Hair of Different Lengths

Do you have a family history of hair loss? *

Please provide more detail: *

What relation experienced similar hair or scalp problems? Please tick all that apply. *

Mother Father Brother Sister Uncle Aunt Cousins Grandparents

Have you ever been diagnosed with a hair or scalp disorder or disease? *

Please provide more detail: *

Have you ever had a biopsy or culture done on your scalp? *

Please provide more detail: *

Wash & Care

How often do you wash your hair? *

What is your daily hair routine? *

Do you use a hair dryer / heat styler? *

How often do you use a hair dryer / heat styler? *

How many hairs do you lose per day? *

What type of hair products do you use? *

Previous Treatment

Have you made previous attempts to fix your hair or scalp problems? *

What did you try? *

Include transplants, scalp treatments, hair replacement or weave, over-the-counter products, Avacor, hair loss clubs etc.

Health and Wellbeing

Can you recall being ill and/or under stress prior to the problem? *

Please provide more detail: *

Treatment and/or surgical options may take 6 months or more to show success. Are you willing to wait that long? *

Do you have any of the following health problems? Please tick all that apply. *

Do you experience problems with your skin? *

Please provide more detail: *

Are you overly sensitive to the cold or heat? *

Which? *

Describe your energy level: *

Have you lost weight recently? *

Approximately how much weight have you lost? *

Do you have any dietary preferences or intolerances? *

Please provide more details: *

Describe your average daily diet: *

Include your Breakfast, Lunch, Dinner and Snacks. List fruits, vegetables, carbohydrates, protein, etc.

What do you drink every day? *

Water, Juice, Coffee, Tea, Carbonated Drinks, etc. Indicate how many you drink of each.

Do you smoke? *

How many times per day? *

Do you drink alcohol? *

How often? *

Do you exercise regularly? *

Please describe your exercise routine: *

Describe how you feel. Please tick all that apply.

Stressed Nervous Worried Relaxed Easy Going

Where do you feel most stressed? Please tick all that apply.

Work Domestically Personal Relationships Generally

Please rate the quality of your sleep: *

Which areas does your hair loss affect you? Please tick all that apply. *

If other, please provide more detail:

I want to... Please tick all that apply. *

Stop my hair loss Fill the areas where I've lost hair Have a full and normal head of hair Other

If other, please provide more detail:

Photos

If possible, please upload clear photos of your hair loss to help us be better prepared for your appointment:

Front

Top

Left

Right

Back

Client Statement

I hereby confirm that all information provided in this form is true, accurate, and complete to the best of my knowledge and belief.

I understand that it is my responsibility to inform the business promptly of any changes to my contact information, or medical history as this could have an effect on the course of treatment provided.

Please tick the box to confirm: *

I have read and understood the statement above.

Client Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at any time to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.