Intake Form

Personal Information

Name *

Date of Birth *

Phone *

Email *

Occupation

How did you hear about us?

Main Concerns

What are your main hair/scalp concerns? (Check all that apply)

Thinning hair

Bald spots or patchy loss

Receding hairline

Excessive shedding

Scalp irritation or itching

Oily scalp

Dry/flaky scalp

Other

When did you first notice hair loss?

Less than 6 months

6–12 months

1–3 years ago

3+ years ago

Is your hair loss:

Gradual

Sudden

In specific areas only

All over

Is there a family history of hair loss?

Yes, on mother’s side

Yes, on father’s side

Both sides

None / Unsure

Health & Lifestyle

Are you currently under the care of a doctor for any health conditions?

Yes

No

Are you taking any medications, supplements, or vitamins?

Yes

No

Have you experienced any major stress, illness, surgery, or childbirth in the last year?

Yes

No

How would you describe your diet?

Do you smoke or vape?

Yes

No

How many times per week do you exercise?

Hair & Scalp Care Habits

How often do you shampoo your hair?

What type of products are you currently using? (Shampoo, conditioner, treatments, oils, etc.)

Have you ever used topical hair loss treatments before (like Minoxidil or similar)?

Yes

No

Have you ever had chemical services (color, relaxer, keratin, etc.) in the last 6 months?

Yes

No

How would you describe your scalp?

Goals & Expectations

What are your main goals for your hair?

Slowing or stopping hair loss

Regrowing new hair

Strengthening existing hair

Improving scalp health

Increasing volume/thickness

How committed are you to following a consistent daily regimen?

100% committed

I’ll do my best

Not sure / depends on complexity

How soon are you hoping to see results?

Within 1 month

Within 3 months

Within 6 months

Long-term maintenance plan

Consent

I understand that Hair Loss Solutions' topical treatments are designed to promote scalp health and support hair regrowth. Results vary per individual and consistency is key. By signing below, I confirm the information I've provided is accurate to the best of my knowledge.

Signature *

Date *

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