Women’s Consultation

Personal Details

Given Name
Postal Address
Suburb or Town
Postcode or Zip Code
E-mail Address
Work Phone
Home Phone
Mobile Phone
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 have a family history of fine, thinning hair or balding?
 Yes No
Q.3A Which members of your family does it affect? Please indicate which family members;
 father mother brother(s) sister(s) aunts uncles female cousins grand mothers
Q.4 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.5A Is your hair loss:
 a) predominantly through the front, sides, and across the top of the scalp, or b) in very distinct circular patches within which there is very little or no hair present, or c )thinning evenly throughout your scalp

Q. 5B If you answered Q.5A as "a" please indicate which category is most similar to your own:
Q.6 Is there any accompanying ‘sensations’ with your condition, such as:
 tight sensitive scalp itchiness. scaling/flaking or very dry scalp.
Q.6A Have you noticed any changes in the wave movement or manageability of your hair across the top of your scalp, has it:
 become curlier or frizzier was wavy, but now is straighter become more unmanageable than before
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. 9A Has your hair loss been accompanied by:
 an increase in facial or body hair an increased oiliness on your face changes or problems in your menstrual cycle
Q. 9B If you experience problems with your menstrual cycle, please indicate which of the following applies to you:
 Your periods are irregularly 'early' or 'late' each month Or, your menstrual flow varies significantly from month to month
Q. 9C Do you regularly experience PMS symptoms with the onset of your menstrual cycle ?
 Yes No

If “yes” please indicate which of the following applies to you:

 Cramping, 'bloating', low back pain, or pain in your pelvic area Tender, swollen, or “lumpy” breasts Irritable, 'snappy' mood swings Or, weepy, “fragile” or depressed mood Feelings of constant anxiety Pre-menstrual headaches or migraines Diminished sex drive (libido)
Q. 9D Do you have ongoing problems with any of the following:
 Sensitivity to cooler temperatures - particularly hands, feet or tip of your nose? Memory recall difficulty or 'foggy' thinking Unexplained weight increase, particularly around your hips and abdominal area Poor sleep patterns
Q. 9E If you are a post-menopausal woman do you regularly experience any of the following:
 Hot flashes Night sweats Dry, 'ageing' skin Diminished or absent sex drive (libido) Excessive vaginal dryness
Q. 9F Was your menopause prematurely induced by:
 Surgical hysterectomy. Chemotherapy or hormonal medication. Other (please state what medication)
Q. 10 If you answered "a" to Q4, did any of the following happen to you 2-3 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. 11 Do you have any known allergies or sensitivities?
 Yes No
Q. 12 If so, what are you allergic to? (please indicate which foods, medications &/or environmental allergens)
Q. 13 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. 13A 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. 13B Do you consistently experience any of the following:
 Pain and Inflammation Muscle &/or joint pain Recurring Headaches Chronic low grade fever Fatigue & Malaise Chronic Fatigue Syndrome Fibromyalgia Hormone Imbalance Gastro-intestinal discomfort or bloating Nausea & Intolerance for fatty foods Increasing sensitivity to multiple chemicals Recurrent infections
Q. 14 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. 15 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. 16 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. 17Do 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. 17ADo 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. 18 Is your alcohol consumption:
 1-3 drinks daily more than 1-3 drinks daily are you a weekend ‘binge’ drinker?
Q. 19 Do you feel you eat a balanced & nutritional diet?
 Yes No
Q. 19ADo you consume a special type of diet, eg: vegetarian, gluten-free, carbohydrate-free, high protein etc.
Q. 20Describe an average day’s diet for you (breakfast, lunch, dinner, snacks)
Q. 21What FLUIDS would you consume on an average day, and how many of each: (water, juices, coffee, tea, cola or other caffeinated drinks)
Q. 22Do you ‘crave’ sugary/refined foods or caffeinated drinks? If "YES" please detail:
Q. 23 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. 23ADo you feel most tired or are your energy levels lower in the morning or in the afternoon?
Q. 24Over the past 6-12 months, have you gained or lost substantial amounts of weight for no obvious reason?
(please indicate how much weight, & over how many months)
Q. 25Do you feel you are sensitive to the warmth or cold of weather or room temperatures?
(please indicate which)

Q. 26What state best describes your skin, is it:
 dry or scaly & cool to cold moist, sweaty, oily & warm
Is the state of your skin different on your face than it is on the rest of your body?

 Yes No

Q. 27Have you noticed any areas of skin on your body that have become lighter or darker in colour? If so when did this occur, & on which areas of your body are they?
Q. 28Have you noticed any increase/decrease in facial or body hair ?
Q. 28ADo the outer part of your eyebrows appear to have been lost or thinned-out significantly?
Q. 29How would you describe the appearance of your fingernails?
 ‘white spotting’ of the nails? 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’)? thin, soft or flexible nails that break/flake off readily or grow poorly?
Q. 30How 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. 31In 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. 32What do you do to relieve these negative emotions?
Q. 33 Are you able to get some daily or weekly exercise? If so what: ?
 Yes No

Q. 34 Do you regularly experience disturbed sleep patterns?
If "YES", why do you think this occurs?
 Yes No

Q. 35 How often do you wash your hair ?
 Daily ‘couple of times’ per week Less than weekly

Q. 35A What shampooing and/or grooming products do you use (Brands)?
Q. 36Do 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. 37When styling your hair do you:
 use a hot wand/comb use hot curlers blow-dry your hair for long periods with your blow-dryer on a heat or hot setting
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.