Men's Consultation (Copy)

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:

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)

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When did the hair loss start or first become noticeable to you?

Do you think you have an inherited male pattern balding?

Yes

Please choose which category is most similar to your own:

Do you have a family history of fine thinning hair or balding?

Yes

A Which members of your family does it affect? Please indicate which family members:

Father

Mother

Brother(s)

Sister(s)

Uncles

Aunts

If you answered "YES" to Q.3-3A, please disregard Questions 5 & 9.

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 ?

Is there any accompanying ‘sensations’ with your condition such as:

tight sensitive scalp

itchiness

scaling/flaking or very dry scalp.

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

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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

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)

Do you have any known allergies or sensitivities?

Yes

If so what are you allergic to? (please indicate which foods medications &/or environmental allergens)

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.

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 ?

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)

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)

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)

Do 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)

Do 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)

Is your alcohol consumption:

1-3 drinks daily

more than 1-3 drinks daily

are you a weekend ‘binge’ drinker?

Do you feel you eat a balanced & nutritional diet?

Yes

Do you consume a special type of diet eg: vegetarian, gluten-free, carbohydrate-free, high protein etc.

Describe an average day’s diet for you (breakfast lunch, dinner, snacks)

Q. 20 What FLUIDS would you consume on an average day and how many of each: (water, juices, coffee, tea, cola or other caffeinated drinks)

Q. 21 Do 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. 22a Do you feel most tired or are your energy levels lower in the morning or in the afternoon?

How 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’)?

How 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

In 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

What do you do to relieve these negative emotions?

Are you able to get some daily or weekly exercise? If so what: ?

Yes

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

Yes

How often do you wash your hair ?

Daily

‘Couple of times’ per week

Less than weekly

What shampooing and/or grooming products do you use (Brands)?

Do you regularly do any of the following to your hair ? (Please indicate weekly/monthly intervals between procedures).

tint or dye your hair darkertint or dye your hair darker

tint/dye or bleach your hair lighter

have your hair permed

have your hair straightened

If 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.

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