top of page
SERVICES
MEET OUR TEAM
TRICHOLOGY
ABOUT US
FIND US
More
Use tab to navigate through the menu items.
CONFIDENTIAL CONSULTATION QUESTIONNAIRE
CONTACT INFORMATION
Full Name
*
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Home Phone
*
Work Phone
*
Date of Birth
*
Month
Day
Year
Age
*
Occupation
*
Email
*
Referred By:
*
Doctor
Google Search
Facebook
Instagram
TikTok
Internet
Social Media
TV
Radio
Salon
Other
If other, who referred, you?
PERSONAL HISTORY
Allergies:
*
Are you allergic to shellfish?
*
Yes
No
General Health:
*
Previous Surgery with General Anesthesia:
*
Do you have any of the following issues?
*
Stroke
Congestive Heart Failure
Irregular Heartbeat
Hypertension Coronary Artery Disease
Anemia
Depression
Thyroid Disease
Endocrine Disorders
Diabetes
Liver Disease
Rosacea
None of the Above
Presently undergoing treatment for:
*
Physician's name:
*
Date of last physical:
Month
Day
Year
Rate Your Level of Stress:
*
High
Medium
Low
MEDICATION
Please check the category/categories of medication(s) if applicable.
*
Anti-coagulants
Anti-hypertensive
Hormones
Thyroid
Aspirin
Mutlivitamin
Radiation Therapy
Chemotherapy
None of the Above
Please list the name(s) of medication(s) and dosage(s) if applicable.
*
Please list any additional medication(s) or supplements:
*
Do you identify biologically as Male or Female?
*
Male
Female
FEMALES ONLY
Female Issues:
*
Yes
No
Postmenopausal:
*
Yes
No
Are you planning to get pregnant in the next 6 months:
*
Yes
No
Are you currently pregnant or nursing:
*
Yes
No
Do you take contraceptive pills:
*
Yes
No
How long have you been taking them?
*
MALES ONLY
Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
*
Yes
No
Do you have an enlarged prostate or prostate cancer?
*
Yes
No
Next
bottom of page
