Trichology Consultation Form Name * First Name Last Name Email * Date of Birth * Phone (###) ### #### Gender How Many Children Age Of Youngest Child ( If Applicable) Occupation Previous Occupation GP Details Stress Levels 1-10 (1 being lowest) Medications Oral Topical Contraception If you have ticked any above, please give details Family Health History Hair Care Regime & Products Main Hair Concerns General Health Health Changes In The Last Five Years Nutritional Status Omnivor Pescatarian Vegetarian Vegan On A Daily Basis- Tick Any Of These Foods You Eat Sauerkraut Keifir Sprouted Foods Add Any Extra Details If Necessary On a Daily Basis - Tick Any Of These Proteins That You Eat Meat Fish Dairy Lentils Soya Plant Based Add Any Extra Details If Necessary On A Daily Basis - Tick Any Of These That You Consme Fruit/Veg Sugars/Carbs Water Tea/Coffee Alchohol Add Any Extra Details If Necessary On A Daily Basis- Tick Any Of These Carbohydrate Foods Whole Grain and Rice Pasta and Bread Potatoes / Root Veg Add Any Extra Details If Necessary Dietary Restrictions Or Allergies Foods You Love Foods You Dislike Any Supplements You Take Recent Dietary Changes How Active Are You Sedentry Lightly Active Moderately Active Very Active Add Any Extra Details If Necessary In The Event Of A Physical Consultation, I Am Happy To Consent To Having My Condition Looked At / Photographed / The Use Of A Microscope Yes No Thank you!
