Client Health and Lifestyle Form
Date of last physical exam?*
Are you currently taking any medications that we should be cognizant of, as they may contribute to your hair loss?*
Have you undergone treatment for any of the following conditions?
(check only what applies)*
Do you now or have you? (check only what applies)*
Family Hair and Health History:
Which side of your family is experiencing hair loss? (Only check what applies)*
Are there any known health issuse in your family? (If so please list below)*
Personal Everyday Lifestyle:
Candy/ Sweets Consumption*
Now Let's Talk About Your Scalp and Hair:
How would you describe your hair type?*
How would you describe your hair texture?*
How often do you shampoo your hair?*
Which chemical process do you use if any?*
What is your preferred method for securing your hair at night?*
What heated styling tools do you use on your hair if any?*
Do you get your hair professionally done?*
Have you ever employed the service of anyone to correct your hair loss?*
Have you ever visited a dermatologist?*
MUST BE COMPLETED BY ADMIN ONLY
تم تحديد وضع الرسم. يتطلب الرسم استخدام الماوس أو لوحة اللمس. لإمكانية الوصول إلى لوحة المفاتيح، حدد كتابة أو تحميل.
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. 🙏🏾💜🙏🏾
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