I have you fill this out prior to your appointment for a couple reasons.

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1. This gives me a chance to get information together that pertains to your specific situation (medications, health history, etc.)

2. In some specific cases I can't help and these questions allow me to see if that's the case. If I can't, I will send you in the right direction.

3. Having this information prior to the analysis allows me to truly listen to your story and ask more in depth questions to figure out all the pieces that are contributing to your hair and/or scalp problem.

4. The signature at the bottom is consent for treatment. I will not proceed without it.

 

Some of these questions are more private and medical. If you are uncomfortable submitting specific answers please leave them blank. We will discuss them in person. My system is HIPPA compliant and the answers go into your specific profile where only I can access them. 

 

There are a few reasons why I ask you about all of your medications, supplements and medical history. 

 

A lot of medications can cause hair loss, but because it isn't seen as a deterrent from taking the medication, most doctors won't tell you unless you specifically ask. They can also cause specific nutrients to be deficient, which can affect the hair and scalp. 

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I like to know what supplements you are on so that I can see if there are any gaps in the vitamins and minerals your hair specifically needs. 

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Your medical history directly effects your hair. Surgeries can take a toll on hair for up to 2 years. Severe illnesses, life stressors, and going on and off medications can all cause major hair changes for up to 9 months.

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Looking at all of these factors ensures I am looking at the whole picture and am not missing a piece that might be crucial in ensuring your results.

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Again if you have any questions or concerns please text me at 262-709-8018