The Hair Loss Centre | Form

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Online consultation

Step 1 of 8 - Personal details

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Title*
- Mr
- Mrs
- Miss
- Ms
First Names*
Surname*
Street & Number*
Town/City*
Country*
Postcode/Zip*
Email*
Confirm Email*
Telephone
Telephone*
Best time to call*
Sex*
- Male
- Female
Your Age*
How did you hear about The Hair Centre?
Is the problem you are experiencing:
- Hair loss?
- Scalp Problems?

Are you experiencing hair loss
- On the top of your head only
- On the top and sides of your head (all over scalp)
- At the front (receding hairline)
- At the back/vertex area
- Is the hair loss sudden with smooth, round bald patches appearing in less than 3 months
How long have you suffered with hair loss or thinning?
Approximately how much hair are you left with on the head?
Approximately how much hair are you left with in the affected areas?
Have you experienced total hair loss on your head?
- Yes
- No
Have you experienced total hair loss on your face?
- Yes
- No
Have you experienced total hair loss on your body?
- Yes
- No
Is there a history of hair loss in your family? If so, which family member(s)?
- Father
- Mother
- Grandparents
- Uncle
- Brother or Sister
Is your hair type

Is your general health and fitness:
Further comments on health and fitness
Are you under constant pressure or stress?
- Yes
- No
Do you work in an environment that exposes you to chemicals on a daily basis?
- Yes
- No
Have you plaited or braided your hair in the past 5 years?
- Yes
- No
Do you use extensions or a weave-on?
- Yes
- No
Do you plait or braid your hair?
- Yes
- No
How often do you wash your hair?
Do you use chemicals on your hair? e.g. bleach, perm solutions, hair colourings, relaxers or any other.
- Yes
- No
Is your scalp
- Flaky?
- Itchy?
- Dry?
- Oily?
- Normal?
- Have spots or acne?
- Prone to dandruff?
Does your scalp weep?
- Yes
- No
Is there a crust built up on your scalp?
- Yes
- No
Please describe any other skin problems on your body or face.

What is your current blood pressure level? (Please have this measured by a reliable person i.e. your G.P.)
Have you had a blood test in the last 12 months?
- Yes
- No
Do you have any of the following conditions?
- Anaemia
- Crohn's Disease
- Depression
- Diabetes
- Endometriosis
- Gynecomastia
- HIV
- Hepatitis B
- Hormone Imbalance
- Hypertension (High Blood Pressure)
- Hypotension (Low Blood Pressure)
- Liver Problems
- Migraine
- Pheochromocytoma
- Polycistic Ovarian Syndrome
- Porphyria
- Prostate Cancer
- Prostate Problems
- Renal Failure
- Thyroid Problems
Other conditions, or expand on previous answers:
Are you currently having treatment by chemotherapy and/or radiation therapy?
- Yes
- No
Do you take any prescription medicines?
- Yes
- No
Do you have an iron deficiency, or any other form of dietary deficiency?
- Yes
- No
- Unsure
Do you have an allergy to lactose?
- Yes
- No
Do you have an allergy to caffeine?
- Yes
- No
Do you have any other allergies?
- Yes
- No
What form of contraception do you use, if any?
- The Pill
- Barrier Contraceptives (ie condoms)
- Dianette
- Other
Have you recently given birth?
- Yes
- No
Do you breast feed?
- Yes
- No
Have you, or anyone in your immediate family suffered from breast cancer?
- Yes
- No
Are you, or is your partner currently pregnant?
- Yes
- No
Will you be trying for a child in the next 12 months?
- Yes
- No
Have you had a raised temperature/fever due to illness in the last 3-6 months?
- Yes
- No
Do you give blood (are you a blood donor)?
- Yes
- No

If you have used any of the treatments listed below for hair loss or a scalp problem please let us know:
Nourkrin
- Yes
- No
Procerin
- Yes
- No
Provillus
- Yes
- No
Revivogen
- Yes
- No
Regaine Liquid
- Yes
- No
Regaine Foam
- Yes
- No
Propecia
- Yes
- No
TRX2
- Yes
- No
Other Treatment(s)
Have you received treatment or advice from:
- Trichologist
- Hairdresser
- Dermatologist
- G.P.
- Other

What type of diet do you have?
- Mixed diet
- Lacto Vegetarian (milk/cheese and vegetarian diet)
- Pescatarian Diet (Fish and Vegetarian Diet)
- Vegan (Purely Vegetarian)
Do you take any mineral or vitamin supplements?
- Yes
- No
Please give mineral or vitamin supplement details
Has your weight changed dramatically in the last 12 months?
- Weight loss
- Weight gain
- No dramatic weight change
How many kgs / Lbs, over how long?

If you have any extra comments about your hair loss or scalp problem please inform us in the space provided.
Please confirm the following to complete the consultation:*
- I agree that the information i provided is accurate to the best of my knowledge.

We request that you provide us with photos of your hair loss. Please refer to the photo examples underneath for a guide to taking the photos. If you do not have photos then you can complete the form without uploading by pressing the ‘complete form’ button below. We do ask that you provide us with photos – you can alternatively email to info@haircentre.co after you have submitted the form. Please make sure you provide your name in the subject line.
Accepted file types: jpg, gif, pdf, png, doc, docx.

The Hair Centre’s online consultation gives our trichologist all of the information required to diagnose your hair loss condition and then we can recommend an effective course of treatment for home-use. Once you completed the form you will be asked to upload photos of your hair loss. If you can do this we would find this extremely helpful in diagnosing your condition.

Please answer the questions as accuraltey as you can and we will get back to you in 24 hours.

THE HAIR LOSS CENTRE – LOCATION

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THE HAIR LOSS CENTRE

0207 152 4473

52 Grosvenor Gardens, Victoria, London SW1W 0AU
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