Hair Wellness Profile

Hair loss can have many causes, including nutrition, medications, genetic factors, and stress. By sharing a bit about your health and lifestyle, you’ll help us better understand the potential causes and create a personalized plan to support the healthiest hair and scalp possible. This portion of the form should take about 5 -7 minutes.

General Info

Full Name

Date of birth

Phone *

Email *

Address

Street Address

City

State

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal code

How Did You Find Us?

Doctor

Google Search

Social Media

Salon/Barber

Other

If referred by an individual please list their name

Gender

Male

Female

Hair and Scalp Conditions

Please choose how your scalp feels?

Dry

Oily

Normal

Dandruff

Ohert

Do you have any redness or itchiness on your scalp?

Yes

Do you have any bumps or raised areas on your scalp?

Yes

Do you have recurrent attacks of patchy loss?

Yes

Do you pull your hair?

Yes

Any loss of hair on the Body?

Yes

If yes, what area?

What age did you notice hair loss?

Was it sudden or gradual?

sudden

gradual

Please select any areas that you may have current hair loss.

All Over Scalp

Front

Crown

Below are a few examples of these different areas

All Over Scalp

Front

Crown

Is your hair loss getting worse?

Yes

How many hairs per day?

25-100 is considered normal

Is your hair loss concern caused by any medical problems or medications that you are aware of?

Hair Care

On average how many times a week do you shampoo your hair?

What shampoo and conditioner do you use regularly?

Do you use a hair dryer?

Yes

What temperature do you use your hair dryer on?

Hot

Medium

Cold

Unsure

When hair is wet do you use a towel to rub it dry?

Yes

Do you color your hair?

Yes

How Often?

What are your goals and expectations?

Prevent Further Loss

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

Please indicate where hair loss bothers you the most.

No variation in hairstyle

Going outside on windy days

Social Life

Seeing old friends

Participating in sports

Overall appearance

Conscious of appearance at work

Seeing pictures/videos

Wearing hats when going out

Swimming or getting caught in the rain

Overall self-esteem

Meeting new people

People make comments

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

Growth Factors

Low-Level Laser Therapy

Platelet-rich Plasma

Rogaine/Minoxidil 5%

Finasteride / Propecia

Laser Cap

Microneedling

Transplants

Hair Replacement/ Wigs

SMP

XTC

HLCC

Bosley

Hair Club

Keeps

Hims/Hers

Nutrafol

Keranique

In The Last 30 Days, How Have You Felt About The Following Categories?

Body Composition and Pain

I experienced frequent physical pain and carried excess or unhealthy body weight.

I dealt with occasional discomfort or stiffness and struggled with weight management.

I maintained a stable body weight with minor aches or tension, but nothing debilitating.

I felt physically well, maintained a healthy weight, and experienced minimal discomfort.

I consistently felt lean, strong, and free from chronic pain or physical limitations.

Energy Levels and Sleep

I consistently felt fatigued and experienced poor or unrestful sleep.

I often felt tired, with inconsistent or suboptimal sleep quality.

had a balance of good and tired days, with variable sleep quality.

I generally felt energetic and experienced refreshing sleep on most days.

I consistently felt energized and well-rested, with high-quality sleep throughout the month.

Fitness and Mobility

I often felt mentally foggy, anxious, or experienced frequent emotional lows.

I occasionally struggled with mental clarity or mood stability throughout the day.

I experienced a mix of focused and unfocused days, with some mood fluctuations.

I generally felt mentally alert, with good focus and a stable, positive mood.

I consistently felt sharp, clear-minded, emotionally balanced, and optimistic.

Hereditary

Please Describe your Family with the following categories - Bald, Thinning Hair, Not Bald, Unknown

Parents

Bald
Thinning
Not Bald
Unknown
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Grand Parents

Bald
Thinning
Not Bald
Unknown
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Siblings

Bald
Thinning
Not Bald
Unknown
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Aunt

Bald
Thinning
Not Bald
Unknown
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Uncle

Bald
Thinning
Not Bald
Unknown
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Medications

Have you had surgury that involved anesthesia in the last 6 months?

Yes

Please List Any Allergies

Are you taking any of the following?

Anti-coagulants

Anti-hypertensive

Hormones

Thyroid

Asprin

Multi-vtiamins

Radiation Therapy

Chemotherapy

Other medications and/or supplements

If Yes, Please List the dose/brand/time on medication

Gender Specific Questions

Have you gone through menopause?

Yes

Are you currently using birth control pills?

Yes

Do you experience challenges with your menstrual cycle (pain, irregularity, etc.)?

Yes

Are you pregnant or breastfeeding at this time?

Yes

Do you plan to become pregnant within the next 6 months?

Yes

Have you ever taken, or are you planning to take, a PSA blood test for prostate cancer screening?

Yes

Have you ever been diagnosed with an enlarged prostate or prostate cancer?

Yes

Nutrition

Are you a vegetarian?

Yes

Have you lost weight in the last 6 months?

Yes

If Yes, How Much Weight?

How many servings of the following nutrients do you get daily?

Fruit

Caffeine

Carbohydrates

Vegetables

Protein

I agree to be evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced consultant. All other checkups are included with the program's cost, which includes monthly and/or quarterly digital and microscopic pictures, for which I give my consent. I further understand results will vary depending on a large number of factors. I acknowledge that it is my responsibility to the company for any changes in my condition, no matter how slight.

Yes