title

Men’s Consultation

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?
 Yes No
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?
 Yes No
Q.4A Which members of your family does it affect? Please indicate which family members:
 father mother brother(s) sister(s) aunts uncles
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 scalp itchiness. 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 greasy hair & scalp both dry scalp 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 anaesthetic suffer blood loss from an injury or procedure suffer an allergic reaction to something illness in which you experienced a high temperature or fever food poisoning and/or severe vomiting & diarrhoea receive 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?
 Yes No
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/rhinitis thyroid gland problems diabetes or unstable blood sugar/insulin levels blood 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 daily more than 1-3 drinks daily are you a weekend ‘binge’ drinker?
Q. 18 Do you feel you eat a balanced & nutritional diet?
 Yes No
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 endurance low or tired much of the day energy 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 mishaps continually stressed, tense or easily irritated by life’s minor mishaps worrisome, nervous or often anxious which you mostly internalise angry/agitated; becoming verbally or physically aggressive with minor provocation continually stressed with feelings of high anxiety depressed with feelings of sadness or hopelessness
Q. 25In what area/s of your life do these feelings prevail?
 your place of employment or business personal relationships home and family life generally 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: ?
 Yes No

Q. 28 Do you regularly experience disturbed sleep patterns?
If "YES", why do you think this occurs?
 Yes No

Q. 29 How often do you wash your hair ?
 Daily ‘Couple of times’ per week Less 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 darker tint/dye or bleach your hair lighter have your hair permed have 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 endurance Libido (sex drive) with your erections less firm Less enjoyment for life Work performance and motivation Do 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.