Female Prequalification Questionnaire
1. HOW LONG HAVE YOU BEEN LOSING YOUR HAIR?
2. WHERE IS THE HAIR LOSS?
3. DO YOU HAVE HAIR ON THE BACK AND SIDES OF YOUR HEAD? IS THAT HAIR THICK AND NOT PATCHY?
4. DO YOU HAVE A THYROID CONDITION OR HORMONE CONDITION? IF SO, IS THAT CONDITION STABLE?
5. HAVE YOU SEEN A DERMATOLOGIST ABOUT YOUR HAIR LOSS? IF SO, WHAT KIND OF ALOPECIA DID HE/SHE DIAGNOSE YOU WITH?
Androgentic (runs in the family) - Good candidate and may be seen by a consultant.
6. HAVE YOU EVER TRIED ROGAINE, A HAIR SYSTEM, OR ANYTHING ELSE FOR YOUR HAIR LOSS?
7. IS YOUR MAIN CONCERN: RE-GROW LOST HAIR, TO MAINTAIN WHAT YOU HAVE, OR BOTH?
ADDITIONAL:
- Are they taking any taking any medications? Did the hair begin to fall out before they started the medication? Could the medication be the cause for their hair loss? If yes, they need to see a dermatologist.
- Stress - Ask how long she has been losing her hair - androgentic hair loss is usually slowly over time. Stress can cause hair loss, ask if it has been more then a year since they had hair growth in that area. No hair re-growth for more then a year, then they are a possible candidate.
- Pregnancy - If there has been no more loss or re-growth for more then 1 year after the baby was born, a consultation can be made.
- Hormones - If her condition is stable and there has been no re-growth for more then 1 year, then a consultation can be made.
- Chemicals - If she has loss due to chemicals, such as perms, relaxers, straighteners, she must not have used any of them for 1 year and had no re-growth for 1 year in order to qualify as a possible patient.
- Alopecia Areata - If client has been diagnosed by a doctor to have this condition, they are not a candidate for our procedure.
- Alopecia Universalis - If client has been diagnosed by a doctor to have this condition, they are not a candidate for our procedure.
CAUSES FOR FEMALE HAIR LOSS WE DO NOT TREAT:
Physical stress: Surgery, illness, anemia, rapid weight change.
Emotional stress: Mental illness, death of a family member.
Medication: Drugs used to treat cancer, blood thinners, anti-depressants and high blood pressure medications, as well as birth control pills and high doses of vitamin A, may all cause hair loss.
Diet: Too little protein and too little iron in the diet can lead to hair loss.
Illness: Hair loss may begin one to three months after a stressful situation, such as major surgery. High fevers, severe infections and chronic illness can result in hair loss.
Childbirth: A high degree of hair loss may occur within two to three months after delivery.
Alopecia aerate: A condition in which hair loss occurs only in certain areas, resulting in hair loss patches the size of a coin or larger.
Thyroid disease: An overactive or under active thyroid can cause hair loss.
Ringworm: If this fungal infection occurs on the scalp, it can cause small patches of scaling skin and some hair loss.
