Women's Consultation

Last Name*

First Name/s*

Address*

Zip/Post Code

Country

Contact No*

Email*

DOB

Occupation/Profession

Racial Group/Ethnicity*

No. of Children + ages (if applicable)

Weight*

Height*

What are the concerns you are seeking assistance for?

When did you 1st notice your hair loss/scalp problem?*

Did it begin quite suddenly (as shedding or patches)or slowly over time? (Please detail)

Is your hair loss: frontal + across the top of scalp OR ‘all over’ OR ‘patchy’?

Please indicate which category is most similar to your own?

IF hair loss is patchy are the areas (termed:lesions): defined round/oval areas with some OR no hair growing within; appear ‘scarred’ in appearance with little or no hair growth in affected area/s (often has a shiny ‘onion peel’ look to it); inflamed in appearance with active or dry crusting pustules and hair loss (often found around the crown of the scalp). Noticeably receded frontal hairline margin; uniformly receded or with deeper recession at the temples?

Are you aware of any scalp sensations? Tender scalp ‘sensitive‘ to touch a ‘burning’ or inflamed scalp an itching scaling/flaking scalp ‘crawling’ sensations which appear to move around. Other feelings

Has your hair become: more unmanageable OR frizzier/curlier OR straighter noticeable change in texture (top vs. ‘nape’ hair at bottom of scalp)?

Have you previously treated your current problem?

Yes

What/with whom (if applicable)

Do you have a FAMILY history of hair loss?

Yes

IF ‘Yes’ which members

Mother

Father

Sisters

Brothers

Aunts

Grandmothers

Female Cousins

Have you been ill with a high temperature(fever) OR had surgery or medical/dental procedure OR commenced/ceased any medication; injections/vaccinations OR lost weight quickly OR a dramatic change of diet OR been under intense stress in the past 1-3 months? Please detail what when and for how long

Do YOU have any current OR chronic healthproblems (such as thyroid diabetes tonsillitis sinusitis asthma herpes** HIV** Hepatitis (B or C) ** Thalassaemia or inflammatory condition of any kind? – Please list any other*

Please list any current ANY medications or supplements you regularly take or have recently ceased – particularly contraceptive or Hormone Replacement. Please include dosage per day; how long you have been taking OR time elapsed since you ceased*

Do you have ANY known allergies or sensitivities (including OR feel you have MULTIPLE CHEMICAL or FOOD SENSITIVITIES)? If YES what*

Does your FAMILY have a history of allergies(if so what); or eczema psoriasis asthma thyroid issues diabetes(I/II) rheumatoid arthritis?Other autoimmune conditions not stated above

Are you: Post-Menopausal (from what age) OR have you had a surgical Hysterectomy (when - year or age)- for what reason?

Do you presently experience hot flushing OR night sweats?

IF you still have a menstrual cycle are they regular in time + flow

Yes

Do you regard your periods as excessively heavy or contain large clots?

Yes

How often do you get your period + how long does it last?

Do you regularly notice ‘breakthrough’ bleeding?

Pre-menstrually(or at other times) do you experience any of the following in a moderate or severe way

‘lumpy’ or tender breasts

heavy (or heavily clotted) menstruation

‘painful’ periods

cramping or bloating

; noticeable mood swings (teary/fragile OR irritability)

headaches/migraines

decreased sex drive (libido)

sleep disturbance

Have you noticed an INCREASE or DECREASE with

facial +/or body hair

oily T-zone/scalp

coarsening facial skin pores

noticeable acne breakouts

Have you noticed any areas of your skin become darker or lighter? Have you been diagnosed with Vitiligo? (Please details what area of your body and when you 1st noticed changes in skin colour)

Do you regularly experience ANY of the following:Generally feel ‘unwell’; distended stomach bloating or digestive discomfort nausea after eating intolerance to fatty/fried foods or alcohol ‘windy’ (flatulence); constant ‘burping’ or frequent hiccoughs (especially after eating/drinking); persistent bad breath (halitosis)*; irregular bowel movements or continually unformed ‘loose’ or excessively odorous stools; pale stools which resist flushing chronic constipation May indicate Gut ‘flora’ imbalance or dental (flossing) issues.

Have you noticed: increased (unexplained) or rapid weight gain ORweight loss (how much weight change over what time period)? Difficulty shedding added weight; poor concentration/memory recall (termed:‘foggy thinking/brain fog’)?

Describe your ENERGY levels: High energy OR LOW & tired most of the time; energy levels noticeably fluctuate between morning + evening (please circle which time of day); feelings of continual muscle/joint pain or weakness; OR tired most of the day but get a ‘2nd wind’ of energy in the evening (which may keep you up later than you’d like)

Do you feel SENSITIVE to cooler or cold temperature OR heat or intolerant to temperature/weather changes as you move indoors to outdoors?

Do your hands or feet or tip of your nose always seem to feel cold or cooler unrelated to the seasons?

Describe your skin generally: dry + cool/cold OR warm/moist OR dry flaking or scaling skin; prematurely ‘aged’ skin; skin pustules (in what area/s do these pustules/pimples concentrate?)

How would you generally describe you’re the state of your hair and/or scalp: greasy/oily scalp BUTdry/brittle hair dry or itchy or flaking scalp; dry hair ‘plaque-like’ red or scaling lesions OR red/moist or scaling on the scalp.

What is the “average” day’s breakfast, lunch + dinner for you?

Breakfast

Lunch

Dinner

Snacks

Do you continually ‘seek-out’ the ‘quick energy hits’ of sweet/sugary foods OR caffeinated drinks or salty foods/snacks?

What foods DON’Tyou like (or inclined to avoid)?

What fluids do you drink + how much daily?

Water

Juice/s

Coffee

Tea/s

Cola or other ‘energy’ drinks

Other

What type of alcohol AND how many drinks would you have per day on average?

DO you smoke cigarettes; if YES how many per day?

Do you use illicit/’recreational’ drugs; if YES what and for how long?

In what areas of your life do you feel these feelings predominate?

Home/domestic

Family or Personal Relationships

Workplace

General anxiety across all areas of life

Are you able to exercise or engage any relaxation techniques regularly to relieve negative emotions/anxiety?

Do you regularly experience disturbed sleep or insomnia YES/NO Why do you think this happens?

When do you cease BLUE light/EMR (smartphones laptops TV) usage by?6pm 8pm; 12 midnight or ‘leave-on’ + respond to during the night.

What hair cleansing products (Shampoo/Conditioner) other grooming/styling products do you use?

How often do you shampoo/wash your hair: daily; 2-3times per week; weekly monthly DON’T wash your hair with a cleansing product ever.

If applicable do you live in an area of ‘hard’ or bore water; do you rely on tank water for bathing?

Yes

Do you spend extended times in a CHLORINATED pool? If so please detail:

If YES do you physically wash your body (using body wash/shower gel etc) and shampoo your hair at least once? Please detail your usual routine:

Physical Assessment (Please SELF-ASSESS eyes nails tongue where applicable):

Eyes

Pale conjunctiva (inside bottom eyelid)

Yes

Exophthalmia (i.e.: noticeably protruding “stare” eyes often dry or irritated)

Yes

Jaundiced (yellow whites of eyes)

Yes

Blepharitis (red/irritated eyelids)

Yes

Lost/sparse outer 1/3 eyebrows or loss of eyelashes.

Yes

Nails

‘White spotting’ (bright/feint)

Yes

How many……. thin/soft/brittle

Yes

Ridging

Yes

Splitting

Yes

Buckling/breaking/chipping/flaking

Yes

Lifting

Yes

Pitting

Yes

Spooning

Yes

Compromised nail/nail tissue integrity (biting nails or other causes)

Yes

Tongue

‘Mapped’ (deep lines or cracks in your tongue)

Yes

‘Lumpy’ spotted coated – (mustard/yellow OR grey/white) ‘scalloping’ around sides of tongue ‘beefy’ redin appearance

Yes

Red at tip of tongue

Yes

You feel your tongue OR the tip of your tongue is sore or sensitive

Yes

Greasy/slimy or pale ‘white’ tongue or other unhealthy tongue appearance.

Yes

Additional Information (OR otherchanges observed):

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.

Physical Assessment (Please SELF-ASSESS eyes nails tongue where applicable):

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