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Silverado Medical and Aesthetic Clinic

Hair Loss Intake Form

  Last name

  Mid name

  First name
    
Single Married Divorced Widowed
City
Prov.
 Postal
APT#
    
*Cell phone #:
()- -
Evening Phone #:
()- -
Preferred method of contact? Home Work Cell E-Mail
Emergency Contact Details-
His/Her Name: Phone #:
()- -
1. How would you characterize your current degree of hair loss?
Minimal Mild/ Moderate Extensive
2. What is your main area of concern?
Hairline/ Temples Frontal area Crown (top) All Other
If Other:
3. I am experiencing:
Thinning Receding Shedding Breakage Oily Scalp Itchy/Dry/Flaking Scalp
4. Is your hair loss:
Just Starting Accelerating Slowing down Basically done Not sure
5. Hair loss affects me:
When getting dressed in the morning
When meeting new people
Seeing old friends
Whenever I wear a hat
When swimming
At formal events
When people make comments
At work or school
In my overall social life
My overall self-esteem
On windy days
When I see videos/pictures of myself
6. Do you regularly use any form of scalp camouflage (powder,makeup,spray,toppik)
Yes No
7. Tried any of the following to prevent hair loss?
Propecia/Proscar
Rogaine/Minoxidil
Avodart/Dutasteride
Laser Therapy Hood
LaserComb
Vitamins/Supplements
Hair Transplant Surgery
Special Shampoo
Other
Non of the above
8. Are you currently taking Propecia/Proscar?
Yes No
- Do you feel it has been effective:
Yes No Unsure
9. Are you currently using Rogaine/Minoxidil?
Yes No
2% 5%
- Do you feel it has been effective:
Yes No Unsure
Please identify specific areas of intrest:
Propecia
Rogaine/Minoxidil
Hair Transplantation
Hair Care Products
Laser Therapy
Camouflage
Nutritional Supplementation
Eyelashes
Eyebrows
Genetic Hair Loss Test
Other:
If Other:
12. How would you rate the condition of your health:
Excellent Good Satisfactory Fair Poor
13. How would you rate your current nutritional status:
Excellent Good Satisfactory Fair Poor
14. Your current stress management skills are:
Excellent Good Satisfactory Fair Poor
Risk Factors:
Do any of your "blood relatives" have thin hair or hair loss? Yes No
Is your hair part-line widening? Yes No
Is hairline receding or noticed less hair coverage & more scalp showing? Yes No
Have you worn/currently wear a hair piece, hair system,or extensions? Yes No
Lifestyle Factors:
Do you routinely color your hair? Yes No
Do you routinely chemically perm or straighten your hair? Yes No
Do you routinely take a protein shake containing Creatine? Yes No
Do you drink alcoholic beverages? Yes No
Are you a smoker?(or ex-smoker)of cigarettes/cigars? Yes No
Do you/have you taken prescription medication for:
High Blood Pressure? Yes No
Elevated Cholesterol? Yes No
Depression/anxiety? Yes No
Anemia (low iron)? Yes No
Have you ever been diagnosed with:
Hormone Abnormalities? Yes No
Eating Disorder? Yes No
Menstrual Cycle Abnormality? Yes No
Recent Pregnancy? Yes No
Menopause? Yes No
15. Ever had an allergic response or adverse reaction to substances placed on your skin?
Yes No
If so, Please Describe:
16. Are you aware of any allergies you might have to any foods,drugs or medications?
Yes No
- Which? Dairy Fish/ Seafood Other
17. Have you had a hair restoration consultation in the past?
Yes No
If Yes, Where?
18. Have you ever had a hair transplant?
Yes No
If Yes, By Whom?
* To the best of my knowledge, I answered all of the questions in this form accurately. I understand that this program is not a substitute for medical advice and any medical questions will be directed to licensed physician.
OCCIPTL Crown Front Temple
Initial HMI:
Area of Concern:

-Hair Checker Name:
-Time: PM or AM
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)