Confidential Client Evaluation

This form will help us evaluate you hair loss problem, so that we can recommend the appropriate treatment for you. There is no charge or obligation for this evaluation. Please answer all questions that are applicable. All information is strictly confidential.

Part I. Tell us how we can contact you
Name
Address
City
State	LA - Louisiana TX - Texas
Zip Code
Phone (Daytime)
Phone (Evenings)
E-mail
Employer
Occupation
How and when to contact you:	By Phone Mail E-mail Call me: Mornings Afternoons  Daytime Evenings Don't call me

Part II. Tell us about  you and your condition
What is the name of the shampoo you use most often?
What is the name of the conditioner?
Your hair type is Dry Oily Normal
How often do you shampoo your hair?
Do you perm or color you hair? Yes No
You consider you hair to be Fine Medium Coarse
Do you have any allergies? Yes No
If you have allergies, what are they to?
Do you take any medication on a regular basis? Yes No
If you take medications, what are they?
Have you been treated by a dermatologist for any skin problem? Yes No
If you answered yes to the above, what are/were the skin problems?
Have you had any major illness or surgeries before you noticed hair loss? Yes No
If you answered yes to the above, please explain.
Is balding hereditary in your family? Yes No
If you answered yes to the above, please explain.
You are losing your hair Slowly Quickly
How old were you when you first noticed you were losing your hair?
Did you have any scalp disease or dandruff at the time you started to lose your hair? Yes No
If you answered yes to the above, please explain.
Do you have any itching, burning, or tingling on our scalp? Yes No
If you answered yes to the above, please explain.
What type of sports activities do you participate in?
The diagrams on the right have been designed to identify the pattern of hair loss as well as the percentage of hair loss. Different patterns and percentages are treated differently by a Hair Replacement Specialist. Please indicate the one that is closest to our hair loss. Please selct A B C D E F G H I J K L