Consultation Questionaire

BOOK HAIR CARE EXPERIENCE

BOOK a THERAPEUTIC MASSAGE

First name

Last name

Address

Birthday

Month

Day

Year

Phone

History

Allergies?

Are you allergies to shellfish?

General Health:

Poor

Fair

Good

Excellent

Previous Surgery with General Anesthesia/Date

What is your blood type?

PRIMARY REASON FOR VISIT:

Presently Undergoing Medical Treatment for

Type of Practitioner

Date of last physical

Stress:

High

Medium

Low

Medications/Supplements/Herbs: Please list the name(s) of any medication(s) and/or supplement(s) that you take daily and the dosage.

Birth Control?

Female Only

Female issues

Yes

Post Menopausal

Yes

Are you planning to get pregnant in the next 6 months?

Yes

Are you currently pregnant or nursing?

Yes

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?

Yes

Do you have an enlarged prostate or prostate cancer?

Yes

Nutrition

Are you a vegetarian?

Yes

How many servings of protein do you get a week?

Servings of red meat per week

Snacks

How many glasses of water do you drink each day?

List any foods you crave:

Your present weight is:

Gained or lost weight recently?

How much?

Do you consider yourself to be?

Underweight

Average

Overweight

Conditions of Hair and Scalp

Scalp

Dry

Oily

Dandruff

Yes

Redness

Yes

Itchy scalp only:

Yes

Painful/Sore scalp:

Yes

Bumps or raised areas:

Yes

Do you pull your hair?

Yes

Recurrent attacks of patchy loss:

Yes

Goose Bump feeling:

Yes

Hair of different lengths:

Yes

Areas of hair loss:

All over scalp

Front

Crown

Other

Have you been diagnosed with?

Alopecia Areata

Totalis

Universalis

Did you lose any hair at a young age?

Yes

How old were you?

Any loss of hair on body?

Yes

What area?

Any loss of eyebrows or eyelashes?

At what age did you notice hair loss?

Was loss sudden? or gradual?

Is your hair loss getting worse?

How many hairs lost per day?

What kind of shampoo & conditioner do you use?

How many times per week do you shampoo?

Do you use a hair dryer?

Yes

What temperature?

Hot

Medium

Cool

When hair is wet, do you use a towel to rub dry?

Yes

Is your hair loss caused by any medical problems or medications that you are aware of?

HEREDITY

Does hair loss run in your family?

Yes

BALD - THINNING HAIR - NOT BALD - UNKNOWN

Parents

Yes

Grandparents

Yes

Aunt/Uncle

Yes

Siblings

Yes

How much does your hair loss bother you?

Slightly

Moderately

Highly

Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products are directed by physicians.

Yes

What are your goals and expectations?

Prevent further loss

Gain back hair quickly

Gradually gain back some hair

Other

Knowing that treatment suggestions may take 6 months or more to show success, are you willing to wait that long?

Yes

Consent for Consultation

I am being evaluated by MD Studio & Spa, and understand I will first undergo a comprehensive preliminary evaluation by one of the experienced hair loss consultants. This evaluation will determine if I am a suitable candidate for treatment prior to having my chart reviewed by a specialist. I understand that the cost of the initial evaluation is $99.00. This preliminary evaluation will include a complete and thorough health and hair loss questionnaire, a scalp evaluation which includes standard photography (no face shown), and microscopic photography for which I give consent. I give permission for documentation and photographs of any pre-existing problems to be taken, used, and published by the trichologist at MD Studio & Spa. I also understand that although MD Studio & Spa has had many extremely successful clients, each client is different and like any cosmetic treatment results will vary depending on a large number of factors. I acknowledge that it is my responsibility to inform the office of any changes in my health condition no matter how slight and agree to read all product labels and treatment information provided to me so I can understand my treatments and get the best possible results.

I understand that I am here to learn about nutrition, better health and hair practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is personal counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit as an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters and hair matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease. I understand some general suggestions will be made based on the initial consultation and if it is determined that I am a candidate for a prescription treatment program, a referral appointment will be advised with a physician. I also understand it is my responsibility to keep my appointment with the doctor.

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