Distance Assistance Questionnaire

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Distance Assistance Questionnaire

Why not take advantage of this free hair/scalp assessment offer?

HAIR and SCALP ANALYSIS - "DISTANCE ASSISTANCE QUESTIONAIRRE"

Please tell us about yourself:

Title
First Names
Surname
Address 1
Address 2
City
County
Postcode/ZIP
Country
Telephone
Fax
E-mail
Date of Birth	(DD/MM/YYYY)
Sex
Type of work you do
Skin/Hair Type
Your Height
Weight
The Hair
Hair Type
Texture
Hair Condition
Chemical Applications
How Often?
Shampooing
Which Shampoo do you use?
How often do you shampoo?
Do you use a conditioner?
How often?
Hair Loss
Please Describe your hair loss. Does it effect
Has your hair become thinner during the past
Do you notice excess hair fall?	When you shampoo On your pillow when you wake
Have you had a recent blood test ? It would make assessment easier if you obtained your test results and copied the results below.
Hormone profile results
Thyroid results
Anaemia results
Ferritin results
Other results
Does any type of hair loss run in your family (Genetic) ?
Scalp
Is your scalp flaky?
Is your scalp
Is your scalp itchy or irritable
Is your scalp tender?
Do you suffer from Excema, psoriasis or similar condition?	No Yes
Do you have sores, spots or rashes on your scalp?	Please give details
Does your hair appear oily or damp at the roots when you wake up?	No Yes
If you scratch your scalp do small patches of scale with hairs attached come out?	No Yes
Diet
Do you follow any specific eating pattern?
If you are not sure please fill in a sheet of paper listing what you would normally eat in one
Other
Do you take nutritional supplements? If so which:
General Health
Have you suffered any illness in the last twelve months?	No Yes
If yes please specify illness and duration
Are you taking any prescription medicine?	No Yes
If yes please write down name(s) of drugs, dosage and length of time you have been taking them
Do you think you suffer from stress?	No Yes Sometimes
Do you suffer from allergy to any scalp products	No Yes
If yes specify
For Women Only
How many children have you?
Age of Youngest
Have you recently given birth?	No Yes
Is your menstruation
How many days losing?
Do you suffer from excessive hair growth on
Do you take the Contraceptive pill?	No Yes
If 'Yes' which type
Any recent occurrence of 'Acne' type symptoms or increased facial oiliness?	No Yes
Any unaccountable change in your body weight?	No Yes

THE HAIR & SCALP CLINIC
TRICHOLOGY HOUSE
4 WARRINGTON ST
ASHTON UNDER LYNE
LANCASHIRE
OL6 6XB

TEL/FAX +44 (0)161 330 1547

E-Mail: info@trichology.co.uk

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