A Touch of Faith Hair Care, Inc.™ CLIENT CONSULTATION FORM

Welcome to A Touch of Faith Hair Care, Inc.™ To provide you with the most effective care and professional support, we ask that you complete this confidential consultation form thoroughly and honestly. This form includes detailed questions that may be sensitive but also necessary and required by the Board of Trichology. Please know that all information shared is held in the strictest confidence and used solely for the purpose of assessing and addressing your hair and scalp needs. The more accurate and complete your responses, the better equipped your Trichologist will be to tailor a safe and effective treatment plan that truly supports your well-being. Omitting or withholding information—intentionally or unintentionally—can directly impact your results, delay progress, or in some cases, pose health risks. If you're unsure about any questions, please do not hesitate to ask for clarification. Thank you for trusting us with your care. Your privacy, health, and hair restoration journey are our top priorities.

Date

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number

DOB

Age

Occupation

(Some occupations expose people to toxic chemicals: graphic artist working with dyes or pigments, auto mechanics / auto body repair who work with paints or solvents, hair stylist, office workers who are exposed to toner from copiers, etc. Or have a high stress level: layers, sales, police, and students)

PERSONAL HISTORY

Allergies

Are you allergic to Shellfish?

Yes

General Health

Previous Surgery with General Anesthesia:

(Especially recent surgery as general anesthesia or the stress of the surgery may cause a shed. Important to know if a woman has had a hysterectomy which will cause some hormonal shift even if she is on hormone replacement therapy.)

Presently undergoing treatment for:

Physician’s name:

Date of last physical:

Stress Level

High

Medium

Low

MEDICATIONS

Please list the name(s) of medication(s) and dosage(s) if applied. *Type N/A if none apply* Many medications may cause hair loss as a side effect. Most common are anti-coagulants such as heparin, warfarin (Coumadin), Anti-depressants, hormones (birth control as well as HRT), some thyroid medications, and statins (cholesterol lowering drugs). **CLIENTS SHOULD NEVER STOP MEDICATIONS WITHOUT CONSULTING THEIR DOCTOR.

Anti-coagulants:

Anti-hypertensive:

Hormones:

Thyroid:

Aspirin:

Multivitamins:

Radiation Therapy:

Chemotherapy:

Please List any additional medications:

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

FOR WOMEN ONLY

Are you post menopausal?

Yes

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

Yes

Are you currently pregnant or nursing?

Yes

Do you take Contraceptive Pills?

Yes

If yes, how long have you taken them?

FOR MEN ONLY

Men who have enlarged prostate or are being checked (PSA) for enlarged prostate, need to let their doctor know they are taking an “anti-androgen (saw palmetto) (XTC’s Supplements) or “Propecia™/Finasteride) as they may cause the PSA to have lower value than it really is. The doctor may suggest he discontinue taking the supplement for a week or two, prior to having this test performed; for a more accurate reading of their level.

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?

Yes

Do you have prostate cancer?

Yes

NUTRITION

Diet is particularly important for healthy hair. An adequate protein intake is essential. How much a person needs per day is based on body weight at .8g per kilogram (2.2lbs). The only contraindication on this is a person who needs to restrict protein intake such as someone with kidney disease. Vegetarians who do not eat any kind of animal protein will have a difficult time with adequate protein as there are two types of protein- complete (animal based such as meat, fish, and poultry which includes dairy products and eggs) and incomplete (nuts, legumes, soy, etc) Fruits and vegetables are important, and people should eat a variety of colors for the best nutritional value. Caffeine (coffee, tea, colas, chocolate, energy drinks) interferes with how your body processes B vitamins so excessive use should be avoided. Anyone who has lost a lot of weight in a short period of time (diet, gastric bypass, or bariatric surgery) will lose hair.)

Are you a vegetarian?

Yes

How many daily servings of protein?

Fruit?

Vegetables?

Caffeine?

Carbohydrates?

How many pounds?

Have you lost weight recently?

Yes

HAIR & SCALP CONDITION(S):

Is your scalp

Dry

Oily

Normal

Dandruff

Any redness or itching?

Yes

Do you pull your hair?

Yes

Recurrent attacks of patchy loss?

Yes

Any bumps or raised areas?

Yes

Hair of different lengths?

Yes

Areas of hair loss?

Yes

Any loss of hair on your body?

All over scalp

Front

Crown

Something else

At what age did you notice hair loss?

Some of this information you will notice when you examine the scalp. Dandruff may be a sign of an allergic reaction or an excessively dry scalp. Redness, bumps, raised areas or itching may be a sign of an infection (bacterial or fungal) as well as insect bites or more serious problems such as melanoma. Any raised rash, scaly areas (raised white scaly areas may be psoriasis) or open cuts/wounds should be referred to their physician or a dermatologist. Patchy areas on scalp, eyebrow, facial hair (men), may be alopecia areata. This is usually a sudden hair loss that may progress to Totalis (all the scalp hair) or Universalis (all body hair.) It is thought to be an auto immune disease and usually happens to someone under increased stress. It may only be an allergic reaction, but the cause is not really understood. Hair loss may be a symptom of a disease such as lupus and I usually recommend that people with alopecia areata see their doctor to rule out a serious auto immune disease. Another cause of patchy loss would be scaring alopecia. This is usually seen as a red area that may have some drainage. When it heals, it is very smooth with no hair. A diagnosis of scaring alopecia is usually done by biopsy of the area by a dermatologist. There are no follicles in the scarred areas and regrowth is not possible. The hairs around these areas may be strengthened with treatment and may make these areas easier to hide with other hair. There may also be chemicals (perms, strong chemicals) or physical scarring (heat, accident) where regrowth may not be possible. Occasionally a person with Trichotillomania will come for treatment. These people pull out their hair, eyebrows, eyelashes and may benefit from counseling to find out the cause of this abusive type of behavior. If they continue to pull out their hair, the loss may become permanent.

Was your hair loss

Sudden

Gradual

Is your hair loss getting worse?

Yes

What kind of shampoo do you use?

(Shampoos without sodium laureth sulfate (SLS) or DEA are safer and healthier. SLS may cause irritation and DEA when it sits on the shelf in a cosmetic product may react with other ingredients to form a potent carcinogen called nitrosodiethanolamide (NDEA). These ingredients are added to shampoo because they emulsify the product and provide a rich lather that people think necessary to have “clean” hair.)

What kind of condition do you use?

How many times per week do you shampoo?

Do you use a hair dryer?

(Hair may be damaged with excessive heat.)

Yes

What temperature?

Hot

Warm

Cool

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

(Wet hair is more vulnerable and thinner, weak hair may be damaged when vigorously rubbed.)

Yes

Do you color your hair?

Yes

HEREDITY

If there is no family history, Hair loss may skip a generation, and is carried on several genes so it may randomly show up in family members or carry down from generation to generation on a regular basis.

Does hair loss run in your family?

Yes

Unsure

Select family that applies

Mom

Dad

Grandmother

Grandfather

If not list please add below

How much does your hair loss bother you?

Slightly

Moderately

Highly

What are your goals and expectations?

Prevent further loss

Gain back hair quickly

Gradually gain back some hair

Other

Text

Successful treatment may take 6 months or longer to show visible results. Are you committed to following the recommended plan for the full duration?

Yes

CLIENT LIABILITY DISCLAIMER

I understand that the accuracy and completeness of the information I provide in this consultation form directly affects the quality and safety of the hair and scalp treatments I receive. I acknowledge that if I fail to disclose any relevant medical conditions, medications, hormonal changes, or other personal health factors, A Touch of Faith Hair Care, Inc.™ and its licensed Trichologists cannot be held responsible for any adverse reactions, complications, or ineffective results that may occur as a result.

I have read and agree to the Client Liability Disclaimer.

I consent to proceed with treatment under the terms outlined.