Hair loss
consultation
Female
Male
Work environment
Calm
Moderate
Stressful
Body Weight
Underweight
Normal
Overweight
Fitness level
I don't exercise
I exercise once a week
I exercise 3+ times a week
I exercise daily
Diet
High carb, moderate protein, low fat
High protein, moderate carb, low fat
High fat, moderate protein, low carb
I am experiencing
Long-term hair loss (gradual)
Excessive shedding
Hair breakage and / or damage
Where are you noticing the shedding?
Crown, temple's or middle path
Across the entire scalp
In a patch or line on the scalp
Chemical services done in the past 6 months
Straightening treatment
Colour
Highlights
Perm
Relaxer
When did the hair loss start?
Photo of front of head (looking down)
Photo of back of head (looking up):
Photo of right side of head:
Photo of left side of head:
Do you have any Medical Conditions?
Yes
No
If yes, please specify in as much detail:
Have you had COVID?
Yes
No
If yes, when?
COVID Vaccines
Unvaccinated
1 dose
2 doses
3 doses
Boosters
Vaccine manufacturer
Pfizer
Moderna
Astrazeneca
Johnson & Johnson
Other
Surgery within the last 6 months?
Yes
No
Date of surgery
Type of surgery
Have you had a hysterectomy (female) / vasectomy (male)
Yes
No
Date of hysterectomy
Does anyone in your family suffer with diabetes?
Yes
No
Have you had a check-up regarding diabetes?
Yes
No
Have you ever been diagnosed with PCOS or cycts on the ovaries?
Yes
No
Date of last gyneacologist appointment
When was the last time you checked your iron levels?
When was the last time you checked your Thyroid?
Are you currently on any Medications?
Yes
No
If yes, please specify in as much detail
By submitting this form, you are accepting my Terms and Conditions, Medical Disclaimer and Terms of Use and confirming that all information supplied is to your best knowledge, truthful and most up to date.
Submit
Hair loss
consultation
Female
Male
Work environment
Calm
Moderate
Stressful
Body Weight
Underweight
Normal
Overweight
Fitness level
I don't exercise
I exercise once a week
I exercise 3+ times a week
I exercise daily
Diet
High carb, moderate protein, low fat
High protein, moderate carb, low fat
High fat, moderate protein, low carb
I am experiencing
Long-term hair loss (gradual)
Excessive shedding
Hair breakage and / or damage
When did the hair loss start?
Where are you noticing the shedding?
Crown, temple's or middle path
Across the entire scalp
In a patch or line on the scalp
Chemical services done in the past 6 months
Straightening treatment
Colour
Highlights
Perm
Relaxer
Photo of front of head (looking down)
Photo of back of head (looking up):
Photo of right side of head:
Photo of left side of head:
Do you have any Medical Conditions?
Yes
No
If yes, please specify in as much detail:
Have you had COVID?
Yes
No
If yes, when?
COVID Vaccines
Unvaccinated
1 dose
2 doses
3 doses
Boosters
Vaccine manufacturer
Pfizer
Moderna
Astrazeneca
Johnson & Johnson
Other
Surgery within the last 6 months?
Yes
No
Date of surgery
Type of surgery
Have you had a hysterectomy (female) / vasectomy (male)
Yes
No
Date of hysterectomy
Does anyone in your family suffer with diabetes?
Yes
No
Have you had a check-up regarding diabetes?
Yes
No
Have you ever been diagnosed with PCOS or cycts on the ovaries?
Yes
No
Date of last gyneacologist appointment
When was the last time you checked your iron levels?
When was the last time you checked your Thyroid?
Are you currently on any Medications?
Yes
No
If yes, please specify in as much detail
By submitting this form, you are accepting my Terms and Conditions, Medical Disclaimer and Terms of Use and confirming that all information supplied is to your best knowledge, truthful and most up to date.
Submit
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