Confidential Consultation Questionaire – Hair Reformation Studio

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Our Services
Contact Us
Privacy Policy
Donate
Products
Education Hub
Store

Personal Details

Name *

First

Last

Date *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Date of Birth

Occupation

Email *

Referred By

Personal History

Allergies *

Yes
No

General Health *

Poor
Fair
Good
Excellent

Are you allergic to shellfish? *

Yes
No

Previous Surgery w/General Anesthesia and Date

Are you presently undergoing chemo or radiation therapy? *

Yes
No

Stress Level? *

High
Medium
Low

Do you have any medical conditions? *

Yes
No

Please list all medical conditions:

Areas of Pain

Head
Neck
Shoulders
Arms
Hands
Fingers
Upper Back
Mid Back
Low Back
Hips
Glutes
Legs
Knees
Ankles
Feet
Toes
Other

Are you taking any medications or supplements? *

Yes
No

List your Medications and Supplements: (Note) Please check with your physician to confirm, if any of your medications would have adverse affects with our product supplements or low-level light devices)

FEMALES ONLY

Female issues? *

Yes
No

Post Menopausal? *

Yes
No

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

Yes
No

Are you currently pregnant or nursing? *

Yes
No

Do you take Contraceptive pills? *

Yes
No

How long have you taken them? *

MALES ONLY

Have you currently had or plan to take a PSA (Prostate-Specific Antigen) blood test? *

Yes
No

Do you have an enlarged prostate, prostate cancer? *

Yes
No

Nutrition

Are you a vegetarian? *

Yes
No

How many daily servings of protein?

Lost weight recently? *

Yes
No

How much weight have you lost recently

HAIR & SCALP Condition(s)

Is your Scalp? *

Dry
Oily
Normal
Dandruff

Any Redness or itchy scalp? *

Yes
No

Do you pull your hair? *

Yes
No

Any bumps or raised areas? *

Yes
No

Recurrent attacks of patchy loss? *

Yes
No

Hair of different lengths? *

Yes
No

Areas of concern? *

All over scalp
Front
Crown
Back

At what age did you notice thinning hair? Sudden/Gradual

Is your thinning hair getting worse? *

Yes
No

What kind of shampoo/conditioner do you use?

How many times per week do you shampoo?

Do you use a hair dryer? *

Yes
No

What temperature? *

Hot
Medium
Kool

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

Yes
No

HEREDITY/FAMILY HISTORY

Does thinning hair run in your family? *

Yes
No

What options have you researched for your hair (Including over the counter and prescriptions)?

Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription Products
Avacor
Minoxidil
Clubs or Hair Loss Clinics
Other

How much does your thinning hair bother you?

Slightly
Moderately
Highly

Did you tell anyone that you were coming here today?

Yes
No

What are your goals and expectations?

Prevent further aging & thinning
Gain back hair quickly
Gradually gain back some hair
Other

Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?

Yes
No

Reforming Confidence with every custom hair style!