CONFIDENTIAL CONSULTATION QUESTIONNAIRE
Name
Date
Month Day Year
Date
Address
City
State
Zip
Home Phone
Work phone
DOB
Age
Occupation
E mail Address
example@example.com
TV AD
Internet
Radio
Salon
Other
Allergies
Are you allergic to shellfish?
General Health
Previous Surgery with General Anesthesia
Do you know your blood type? If so, what is it?
Do you have any of the following issues?
Irregular Heart Beat Hypertension (High Blood Pressure)
Coronary
Depression
Endocrine Disorders
Diabetes
Presently undergoing treatment for
Physician's Name
Date of last physical
Month Day Year
Date
High
Medium
Low
Medications: Please list name of medication and dosage
Anti coagulants
Anti hypertensive
Hormones
Multivitamins
Radiation Therapy
Have you started, stopped or changed medication or dosages within the last 3 months? If so, what
Currently taking any medication or supplements? Please List
Female issues
Post Menopausal
Are you planning to get pregnant in the next 6 months? Yes / No
Are you planning to get pregnant in the next 6 months?
Are you currently pregnant or nursing? Yes/No
Are you currently pregnant or nursing?
Doyou take Contraceptive Pills? Yes / No How long have you taken them Year(s)
Month (s)
Is there a known Thyroid imbalance/disease?
Are aware of having Diabetes? If so, what type?
What medications are you currently taking for your Diabetes?
Do you have Anemia?
Is there a known Vitamin D deficiency? Yes No
No
Have you undergone Anesthesia with in the past 3 months? Yes
No
Have you currently had or plan to take a PSA blood test for the screening of prostate cancer? Yes
Yes
No
Do you have an enlarged prostate, prostate cancer? Yes
Yes
No
Have you recently changed your diet?
Are you a vegetarian? Yes / No
No
Have you eliminated or discontinued eating anything? Yes
No If so, how long ago?
How many daily servings of protein?
Fruit
Vegetables
Caffeine
Carbohydrates
Protein
Lost weight recently?
much?
Consent for Holistic Health Consultation
I agree to being evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced consultant. I further understand my results will vary. I acknowledge that it is my responsibility to inform Hair Resolution Center of Brooklyn, LLC of any changes in my health, no matter how slight.
I understand some general recommendations will be made based on the initial consultation.
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CONFIDENTIAL CONSULTATION QUESTIONNAIRE