Hair Loss Consultation
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Referred By* *
What was your assigned sex at birth *
What best describes your hair? *
When did you first notice hair loss? *
Do you currently have any current auto-immune disorders/conditions? *
Are you on any medication? *
Do you experience menstrual irregularities/ PCOS (Poly-cystic ovarian cancer)? *
Do you have any known hormonal imbalances/irregularities? *
Do you experience any iron deficiencies? *
Do you have any known hereditary/genetic conditions? *
Do you experience digestive irregularities? *
Have you done radiation therapy? *
Have you had or currently experience trauma or PTSD? *
Have you done any past hair treatments? *
Are you diabetic? *
Do you currently suffer from Lupus? *
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