Trichology Consultation Questionnaire

ReNu Hair Therapy Salon is a Trichology practice that focuses on using holistic & medical tactics to help you tackle your hair & scalp issues. 

Trichology is the specialized field that focuses on the health of your hair, scalp, and the prevention and treatment of hair loss and scalp disorders with a holistic approach.

To ensure an accurate approach we kindly request that you refrain from washing your hair for at least 48 hours before your consultation. This allows us to gather vital evidence and examine your hair and scalp comprehensively.

During your consultation, it would be beneficial to bring any herbal remedies, medication, shampoos, or other hair care products that you regularly use. Additionally, if you have undergone any recent blood tests or scalp biopsy please bring those results as well. These details will assist us in better understanding your current hair and scalp condition.

We look forward to providing you with personalized care and helping you achieve optimal hair and scalp health!

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Email *
Full Name *
Birthday *
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Gender *
Occupation *
Address *
Phone Number *
Name of Salon & Stylist *
Referred by: *
Required
When did you first notice the hair loss or scalp problem?
 *
Did your problem develop suddenly or gradually over time?
 *
Where does your problem exist? Check all that apply.
 *
Required
Do you have any of the following scalp conditions? Check all that apply.
 *
Required
Do you have any of the following hair conditions? Check all that apply.
 *
Required
Do you have a family history of hair loss? If yes, check as many that apply
 *
Required
Has a dermatologist ever diagnosed you with a hair or scalp disorder or disease? If yes, what was the diagnosis? Name of dermatologist?
 *
Have you ever had a biopsy or culture done on your scalp? If yes, when
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Any relative experienced similar hair or scalp issues? Check all that apply.
 *
Required
Is your hair condition worsening?
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How often do you shampoo your hair? 
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What is your daily hair routine?
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Do you use any form of heat on your hair? 
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Have you made previous attempts to fix your hair or scalp problem? If yes, what did you try? Include transplants, scalp treatments, hair replacement or weave, over-the-counter products, Avacor, Minoxidil ____%, hair loss clubs, etc.
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Can you recall being ill and/or under stress prior to the problem? If yes, what was the event? Treatment and/or surgical options may take 6 months or more to show success. Are you willing to wait that long?
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Have you stopped or started any medications in the last 3 months? If yes, which medications? Include anti-coagulants, anti-hypertensive, hormones, thyroid, aspirin, multi-vitamins, radiation therapy, chemotherapy, etc.
 *
Do you have any major or minor health problems?
 *
Required
Do you take medication or supplements?
 *
Physician's Name?
 *
Date of last physical
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DD
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Do you use recreational drugs? *
Do you have any allergies? *
Have you had any of these tests within the last year? Check all that apply.
 *
Required
Do you experience problems with your skin? Check all that apply.
 *
Required
Medication History
Check all that apply
 *
Required
Describe your energy level *
Have you lost weight recently? If yes, how much? *
Describe your average daily diet. List fruits, vegetables, carbohydrates, protein, etc. (Breakfast, Lunch, Dinner & Snacks) *
How many glasses of water do you drink daily?  *
Do you smoke? If yes, how many times cigarettes per day *
Do you drink alcohol?  *
Required
Do you exercise?  *
Required
Describe how you normally feel emotionally Please check all that apply. *
Required
Where do you feel most stressed? Please check all that apply. *
Required
How is your normal sleeping? Click all that apply  *
Required
What do you do to relieve stress? Please check all that apply. *
Required
Date of last cycle
MM
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DD
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YYYY
How many days does your cycle last?
Are you in menopause? Yes or No and approximately when did you start
If experiencing menopause, do you suffer from any of the following: (please check all that apply)
Are you currently pregnant or nursing?
Clear selection
Are you planning to get pregnant in the next 6 months?
Clear selection
Do you take oral contraceptives? Y / N. If yes, how long have you taken them?
Do you (or did you) often experience PMS symptoms? (please check all that apply)
Have you had a hysterectomy? If yes, full or partial? 
Have you had, or do you plan to take, a PSA blood test for the screening of prostate cancer?
Clear selection
Do you have an enlarged prostate or prostate cancer?
Clear selection
Which areas does your hair loss affect you? (please check all that apply)
 *
Required
Your reason for your visit today(please check all that apply)
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Required
Is balding hereditary in your family? If yes, who?
If you have been advised by other professionals, why have you chosen us? (please check all that apply)
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Required
Do you need someone other than yourself to make the decision to correct your hair loss problem today? Y/N. If yes, please explain.
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