Bloom Hair Wellness Consultation Questionnaire

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Referred by: (friend, internet, Doctor)

Personal History

Allergies: (Shellfish or others)

General Health:

Surgeries/Anesthesia's in the past 2 years, When?

I had my blood work done last on this date:

Do you have any of the following issues? (check all that apply)

Presently Undergoing Treatment For:

List any Medications, Vitamin/supplements or Cancer Therapies

How is your nutrition intake?

Females only:

Do you have Female Issues?

Yes

No

Postmenopausal?

Yes

No

Pregnant or Breastfeeding?

Yes

No

Hair & Scalp Conditions

My scalp is usually: (check all that apply)

Do you pull on your hair?

Yes

No

Areas of thinning or hair loss:

Do you have hair of different lengths? (other than your layers)

Yes

No

Any hair loss on body?

Yes

No

At what age did you notice hair loss?

Your thinning/hair loss was:

Sudden

Gradual

Is your hair loss/thinning getting worse? Tell me about it

What kind of shampoo are you using?

What kind of conditioner do you use?

How many times a week do you shampoo your hair?

If you use a hair dyer, what heat setting do you use it at?

Cool

Medium

Hot

Do you feel your hair loss is do to any medical problems or medications?

Who in your family has had hair loss or thinning?

What hair loss options have you tried?

What options have you researched?

How much does your hair loss/thinning bother you?

Slightly

Moderately

Highly

What are your goals and expectations?

Prevent further loss

Gain back hair quickly

Gradually gain back some hair

Other

Knowing that treatment options may take 6 months to show success, are you willing to wait that long?

Yes

No

What bothers you the most about your hair loss?

Consent for Treatment

I agree to be evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experience consultant. All other check ups are included with the programs 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.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date