Trichologist Shawon Gullette will help you determine the cause of your hair loss. Using the questionnaire below along with a mailed-in sample of your hair, Shawon will be able to better understand the cause of your hair loss and determine the best next steps for treatment. This simple four step process includes: Filling out the form below, paying for the consultation, mailing in a sample of your hair, and receiving the results and treatment recommendation.

Sending in your Hair Sample

1. Collect hair samples in and around the problem area(s)
• Place a white sheet of paper on a table or desk
• Gently rub scalp, comb hair, or brush hair to loosen hairs onto the paper. Make sure some hairs have the bulb attached
• Concentrate on thinning or problem area for sample. Do not cut your hair.
2. Place your hair stands in a sealing plastic bag, labeling it with your full name, phone number and the date.
3. Mail your bagged and labeled hair samples to the provided address that you receive after filling out the questionnaire and payment.

Hair Loss Questionnaire

Name

Email

Address

Phone Number

Referred by:

Gender Male Female

How long have you suffered from hair loss? Select option... 1-3 months 4-6 months 6 months - year 1-3 years 3-5 years 5+ years

Family members with hair loss None Mother Father Grandparents Sibling

Hair Color Brown Black Blonde Gray Red

Location of Hair Loss All over scalp (thinning) Hairline Temples Front of head Top of head Back of head

Do you now or in the past have had any of these medical conditions? Anemia Thyroid High Blood Pressure Diabetes Lupus Hormonal Imbalance Other None

Rate your level of life/work stress Low Medium High

How is your diet? Good Fair Poor

Describe your everyday diet (breakfast, lunch, dinner, snacks)

How often do you typically have a bowel movement? Select option... 2 times per day 1 time per day Every other day Once a week

Describe your energy levels Low or Tired Often High or Energetic Fluctuates During the Day

Are you overly sensitive to temperatures? Yes No

When was the last time you had a blood test? Select option... Recently 6 Months 1 Year 2+ Years

What is the condition of your fingernails? Select Option... Dry Brittle White Spots Piting Ridges Other

Your Hair Type Straight Curly Coarse

Do you use extensions or weaves? Yes No

Do you use any chemicals on your hair? None Relaxer Highlights Color Perm

How often do you color your hair? Select Option Never Every 4 weeks Every 10-12 weeks

How often do you wash your hair? Select Option Every day 2-3 times a week Once a week Once or twice a month

Do you color hair for gray coverage? Yes No

What is the condition of your scalp? Select option... Oily Dry Itchy Flaky Tender Burning N/A

When styling your hair do you use any of the following tools? Flat Iron Blow dryer Hot comb Curling iron None

Have you attempted to address your hair loss in the past? Dermatologist Hair Care Products Rogaine Propecia Hair Transplant None

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Thank You!

Thank you for filling out the Hair Analysis Consultation. Our Trichologist will get in touch with you to schedule your consultation. A paypal button is available below for you to pay for the consultation.

Payment

The $250 consultation fee includes the hair analysis, reports, meeting time with the trichologist, and your customized treatment plan.