CLIENT INTAKE

Enroll for a Consultation

Fill this in before your visit so your appointment starts with the assessment, not paperwork. It takes about ten minutes.

1. Client Information

2. Primary Hair & Scalp Concerns

Main reason for consultation (choose all that apply)
Did the onset happen suddenly or gradually?
Have you noticed specific areas of hair loss?
Have you previously seen a dermatologist or trichologist for this?

Self-assessment below is your own sense of your hair — the practitioner will confirm this during examination.

Hair type (self-reported)
Hair texture (self-reported)
Porosity (self-reported, if known)
Density (self-reported)

3. Medical & Health History

Family history of hair loss or thinning?
Are you currently experiencing high stress levels?
Any major illnesses, surgeries, or high fevers in the past 6 months?
Do you have any of the following conditions?
(For female clients) Pregnant, breastfeeding, or given birth in the last 12 months?

4. Lifestyle & Nutrition

How would you rate your daily diet?
Sudden weight loss or gain recently?
Do you smoke or vape?

5. Hair Care & Styling Habits

What styling methods do you use regularly?
Chemical treatments in the last 6 months

Informed Consent & Acknowledgement

I acknowledge that the information provided above is true and accurate to the best of my knowledge. I understand that a trichology consultation involves an analysis of my hair and scalp — which may include digital or microscopic imaging — and is intended for lifestyle, cosmetic, and non-medical recommendations. I understand that a trichologist does not prescribe medical drugs or replace a medical doctor. I understand my information will be submitted electronically to Limitless Tress for the purpose of preparing for my consultation.
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