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- Model's Agreement Contract
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Client's History Form

*First name

*Last name

*Birthday

Month

Day

Year

*Age

*Street address:

*City:

*State:

*Zip:

*Contact number:

*Number of children:

*Children ages:

0 -2 Months (Newborns)

3 - 11 Months (Infants)

1 - 3 Yrs Old (Toddlers)

3 - 5 Yrs Old (Preschoolers)

6 - 12 Yrs Old (School-age

13 - 19 Yrs Old (Teenagers)

Adults

*Marital status:

Dating

Divorced

Married

Separated

Single

Widow/ Widower

It's Complicated

Work History:

*Occupation:

*Occupation environment:

Inside

Outside

Dirty

Clean

Paint

Chemicals

Hot

Humid

Other

Medical History:

*Date of last physical exam?

Month

Day

Year

*Date of last xrays?

Month

Day

Year

*Are you currently taking any medications that we should be cognizant of, as they may contribute to your hair loss?

Yes

No

Please list the medications that you are currently taking here:

Are there any health concerns that could assist us in comprehending the underlying cause of your hair loss?

*Have you undergone treatment for any of the following conditions? (check only what applies)

Heart troubles

Hypertension

High blood pressure

Low blood pressure

Thyroid Imbalance

Pituitary Imbalance

Blood disorders

Seizures disorders (epilepsy)

Silver fillings

Diabetes

Low blood sugar

Iron deficiency (anemia)

Psoriasis

Keloid (scar) formation

Body building steroid’s

Skin or scalp disorders

None

Other

Long answer

*Do you now or have you? (check only what applies)

Been taking daily vitamins or supplements

Currently dieting

Worn hairpiece

Had hair transplant

Had implants or fusion

Was dieting

Loss or gain more than 15 pounds in the past year

Had/ have any allergies to hair products (if yes, list below)

Had allergies to drugs or medicine (if yes, list below)

Had a recent accident (If yes, list below)

Had recent surgery (If yes, list below)

Been in good health

Regular bowel movement

Irregular bowel movement

Had injury to your scalp

Been under physician care

Been eating a well balanced diet

Had excessive emotional strain (if yes, list below)

Regularly wear hats and hoods

Don't Apply

Long answer

*Emotional stress level

Balanced

High

Low

What contributes to your levels of stress, if any? Have you thought about or tried seeking a psychiatrist?

*WOMEN ONLY!!!

Pregnant

Menopause

Balance menstrual cycle

Contraceptive

Taking hormones

Had a hysterectomy

Don't Apply

Family Hair and Health History:

*Which side of your family is experiencing hair loss? (Only check what applies)

Father’s side

Mother’s side

Both

None

*Mother Side:

Brother

Father

Grandfather

Grandmother

Mother

Uncle

None

*Father Side:

Brother

Father

Grandfather

Grandmother

Mother

Uncle

None

*How long have you’ve noticed hair loss within your family?

*Are there any known health issuse in your family? (If so please list below)

Yes

No

How long have you noticed hair loss within your family? Is there any known health issues on any side of your family?

Personal Everyday Lifestyle:

*Alcohol Consumption

Occasionally

Often

Never

*Candy/ Sweets Consumption

Occasionally

Often

Never

*Drug Consumption

Occasionally

Often

Never

*Soft Drinks Consumption

Occasionally

Often

Never

*6 - 8 Hours of Sleep

Occasionally

Often

Never

Other

Now Let's Talk About Your Scalp and Hair:

*How would you describe your hair type?

Coily (Kinky)

Clean Cut

Curly

Locs

Straight

Wavy

Unsure

*How would you describe your hair texture?

Fine

Medium

Thick

Unsure

*How much time do you spend caring for your scalp and hair? What is your daily hair routine?

*How often do you shampoo your hair?

Daily

Every Other Day

Twice a week

Once a month

*Shampoo presently using?

*Conditioner presently using?

*What types of hair and scalp products do you use?

*Which chemical process do you use if any?

Bleach

Dye

Permanent Wave

Relax

Texturizer

Tint

Don’t apply

*Is your scalp?

Oily

Dry

Itchy

Flaky

Crusty

Red

Inflamed

Healthy

Other

*What is your preferred method for securing your hair at night?

Bonnet or Durag (Satin or Silk)

Scarf (Cotton)

Nothing

*What heated styling tools do you use on your hair if any?

Curling iron

Flat iron (Hair straighteners)

Hair Dryers

Hot air brushes

Hot comb

Multi-styling tools

Don't Apply

List others

*What difference's have you noticed with your scalp and hair?

*Do you feel as if your hair has been damaged? What do you feel is the cause?

*What concerns you about your scalp and hair health?

*What are your long-term scalp and hair goals?

*How often are you able to continue hair treatments with consistency?

*What are your biggest challenges with your scalp and hair?

*If you could change one thing about your hair, what would it be?

*How long have you been suffering with hair loss?

*Current hair loss rate:

10 - 30%

50 - 80%

80 - 100%

None

*Do you get your hair professionally done?

Yes

No

*Have you ever employed the service of anyone to correct your hair loss?

Yes

No

*Have you ever visited a dermatologist?

Yes

No

If answered yes to seeing a dermatologist, please list their diagnose here:

MUST BE COMPLETED BY ADMIN ONLY

Primary diagnosis:

MPB/FPB

Diffused thinning

Hair loss

Alopecia areata

Percent viable in hair loss area:

Emotional stress factors:

Uploads all files: (Video, Images and Documents.)

*Signature

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*Date

Month

Day

Year

We apperciate your prompt completion of our consultation form. We eagerly anticipate your upcoming appointment. Please schedule your visit two weeks from the date you submitted your documentation and pitures. May you have a blessed, safe and prousperous year. 🙏🏾💜🙏🏾

Consultation fee: $250

$

Blessing Families Always Makes My Heart Content

Thank you for your business and for being a loyal customer of Loya17y Cosmetics.

May God bless you and your family abundantly. 🙏🏾💜🙏🏾

© 2020 by Loya17y INC. Proudly created by Snacks Fortune.

COME GET U SOME! 😜

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