PreConsultation Form

Name

Date of Birth

Email

Telephone

Sex/Gender
FemaleMaleRather not say

Your Address

GP Surgery & Name of GP

Your hair loss or scalp concern

Is your hair coloured?

List current medications (inc. dosage & duration)

List of illness and/or surgical procedures within the last 12 months

List of current supplements (inc. dosage & duration)

Have you suffered from any high stress levels, anxiety or depression in the last 12 months

Do you smoke?
NoYes

Allergies

Is there any known hereditary hair loss in your family?

How many times a week do you wash your hair?

List the products you use on your hair including shampoos and conditioners

Δ