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Men’s Consultation

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Personal Details

Surname
Given Name
Postal Address
Suburb or Town
Postcode or Zip Code
Country
E-mail Address
Work Phone
Home Phone
Mobile Phone
Age
Racial Group
No. of Children
Children's Ages
What is your occupation/profession:

 

Q.1 Is the problem you’re seeking help for:
hair loss?damaged hair which breaks off easily?crusty, flaking or itching scalp?other condition (please enter brief description)

Q.2 When did the hair loss start or first become noticeable to you?
Q.3 Do you think you have an inherited male pattern balding?
YesNo
Q. 3A Please choose which category is most similar to your own:
Q. 4 Do you have a family history of fine, thinning hair or balding?
YesNo
Q.4A Which members of your family does it affect? Please indicate which family members:
fathermotherbrother(s)sister(s)auntsuncles
If you answered "YES" to Q.3-3A, please disregard Questions 5 & 9.
Q.5 Did your hair loss commence:
abruptly, with increasingly excessive amounts of hair being shed from 'all over' your scalp?slowly; steady but barely noticeable loss which didn’t become apparent for some time.as distinct circular patches within which there is very scant or no hair growing ?
Q.6 Is there any accompanying ‘sensations’ with your condition, such as:
tight sensitive scalpitchiness.scaling/flaking or very dry scalp.
Q. 7 Is there any accompanying ‘eruptions’ on your scalp, such as:
pustules (pimples with pus in them)rash; if so please mention what colour is it?red skin covered by silvery or white/grey scale

Q. 8 How would you describe your hair and scalp? Is it:
hair & scalp both oily or greasyhair & scalp both dryscalp greasy but hair dry & brittle
Q. 9 If you answered Question 5 as "a", did any of the following happen to you about
2 – 4 months prior to the hair loss commencing:
surgical/dental procedure or have an anaestheticsuffer blood loss from an injury or proceduresuffer an allergic reaction to somethingillness in which you experienced a high temperature or feverfood poisoning and/or severe vomiting & diarrhoeareceive any vaccinations, injections, transfusions or IV antibiotics?experience intense emotional or other stress?commence or cease any drugs – including prescribed medication or ‘body-building’ steroids.experience rapid weight loss from a 'crash' diet or dramatic change in diet (including ‘liver’ or ‘bowel’ cleansing diets)
Q. 10 Do you have any known allergies or sensitivities?
YesNo
Q. 11 If so, what are you allergic to? (please indicate which foods, medications &/or environmental allergens)
Q. 12 Do you have any current health problems or medical issues, such as:
high blood pressure or raised cholesterol levels. Do you take prescribed medication for this ?persistent tonsillitis or ‘enlarged neck glands’, or gingivitis (‘bleeding gums)HIV/AIDS, genital herpes, hepatitis B or C, or other chronic disease ?unrelieved ‘autoimmune’ problem/s such as ‘Lupus’, Sjogren’s Syndrome, etc. Please indicate what condition and when diagnosed.being very overweight.
Q. 12A Do you or your family suffer from any of the following:
skin problems such as eczema/dermatitis or psoriasis.severe allergies, hayfever, chronic sinusitis/rhinitisthyroid gland problemsdiabetes or unstable blood sugar/insulin levelsblood disorders such as ‘Thalassaemia’ or Haemaphilia ?
Q. 13 Do you take any prescribed medications or vitamin/mineral/herbal supplements of any kind?
(please state what drug/s or supplements, the daily dosage you take, & for how long you’ve been taking them)
Q. 14 Do you use any illicit/recreational drugs of any kind?
(please state what drugs, the average amount you’d use daily, & for how long you’ve been using them)
Q. 15 Are you a smoker? If so how many cigarettes per day ?
(please state what drugs, the average amount you’d use daily, & for how long you’ve been using them)
Q. 16Do you regularly consume alcohol? If "YES", what form of alcohol and how many standard drinks on an average day?
(please state what drugs, the average amount you’d use daily, & for how long you’ve been using them)
Q. 16ADo you consider yourself a BINGE DRINKER? If "YES", is this only at weekends or do you drink constantly ?
(please state what drugs, the average amount you’d use daily, & for how long you’ve been using them)
Q. 17 Is your alcohol consumption:
1-3 drinks dailymore than 1-3 drinks dailyare you a weekend ‘binge’ drinker?
Q. 18 Do you feel you eat a balanced & nutritional diet?
YesNo
Q. 18ADo you consume a special type of diet, eg: vegetarian, gluten-free, carbohydrate-free, high protein etc.
Q. 19Describe an average day’s diet for you (breakfast, lunch, dinner, snacks)
Q. 20What FLUIDS would you consume on an average day, and how many of each: (water, juices, coffee, tea, cola or other caffeinated drinks)
Q. 21Do you ‘crave’ sugary/refined foods or caffeinated drinks? If "YES" please detail:
Q. 22 How would you generally describe your energy levels?
high energy and endurancelow or tired much of the dayenergy levels fluctuate between morning and afternoon
Q. 22aDo you feel most tired or are your energy levels lower in the morning or in the afternoon?
Q. 23How would you describe the appearance of your fingernails?
white spotting of the nails? If 'YES' please indicate which fingers and how obvious are they (ie' pinprick spot/s or spots millimeters wide)?'appear ‘heavily ridged’ or buckled nails, or ‘pin-hole’-like indentations in them?Being destroyed by an infective ‘paranychia’, fungal, or other process (including ‘biting them down’)?
Q. 24How would you best describe your typical emotional state ?
‘easy-going’; not dwelling on life’s minor mishapscontinually stressed, tense or easily irritated by life’s minor mishapsworrisome, nervous or often anxious which you mostly internaliseangry/agitated; becoming verbally or physically aggressive with minor provocationcontinually stressed with feelings of high anxietydepressed with feelings of sadness or hopelessness
Q. 25In what area/s of your life do these feelings prevail?
your place of employment or businesspersonal relationshipshome and family lifegenerally and in all areas of life
Q. 26What do you do to relieve these negative emotions?
Q. 27 Are you able to get some daily or weekly exercise? If so what: ?
YesNo

Q. 28 Do you regularly experience disturbed sleep patterns?
If "YES", why do you think this occurs?
YesNo

Q. 29 How often do you wash your hair ?
Daily‘Couple of times’ per weekLess than weekly

Q. 29A What shampooing and/or grooming products do you use (Brands)?
Q. 30Do you regularly do any of the following to your hair ?
(Please indicate weekly/monthly intervals between procedures).
tint or dye your hair darkertint/dye or bleach your hair lighterhave your hair permedhave your hair straightened
Q. 30If you are around midlife (50 years) have you noticed gradual/steady DECLINE in any of the following:
Muscle strength and enduranceLibido (sex drive) with your erections less firmLess enjoyment for lifeWork performance and motivationDo you feel sad,'grumpy' or 'flat' in your mood?Do you feel excessively fatigued in the evening (eg: falling asleep after dinner)?A steady deterioration in your ability to play sports ?Have you lost height and/or increased weight around your abdominal area.
Thank you for your time and patience in completing this questionnaire. When you have submitted this consultation you will be automatically taken to a secure payment form.

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