Hair and scalp problems can be a sensitive and distressing concern. To help us understand your hair problems, please answer as many questions as possible. Your answers will be analysed by trichologist and hairdresser Marilyn Searle. We aim to improve your hair and self-esteem with solutions that are scientific and effective.

SALON MEDICA

MARILYN SEARLE
Holistic trichologist & hairdresser

ADDRESS: 16 Broughton Street, Camden NSW 2570
PHONE: 02 4655 4666
EMAIL: marilyns@cabotclinics.com.au

PERSONAL DETAILS

Full Name (required)

Postal Address (required)

Contact Number (required)

Email (required)

Age (required)

HAIR PROBLEM QUESTIONS

1. How long have you had hair problems?

2. How long have you been losing your hair?

3. Are you losing hair from all over your scalp?
YESNODON'T KNOW

4. Are you losing hair only in patches?
YESNODON'T KNOW

5. Are you losing hair mainly from the top and sides of your scalp (this is known as male pattern baldness)?
YESNODON'T KNOW

6. Is your hair coming out at the roots?
YESNODON'T KNOW

7. Is your hair breaking off at the hair shaft?
YESNODON'T KNOW

8. Is your scalp itchy?
YESNO

9. Do you have dandruff?
YESNO

10. Does your hair look dull and/or unhealthy?
YESNO

11. Is your hair dry or oily?
OILYDRY

12. How often do you wash your hair?

13. What shampoos and conditioner do you use?

14. Do you use synthetic styling products such as hair spray, gel, dry shampoo etc.?
YESNO

15. Do you chemically straighten your hair?
YESNO

16. Do you colour your hair?
YESNO

If YES, with what?

17. Have you ever had a hair and scalp detox treatment?
YESNO

18. Tell me how you style your hair?

19. Do you pull your hair back tight with clips or bands?
YESNO

20. Do you blow dry your hair?
YESNO

21. Do you take prescribed medications?
YESNO

If YES, please list them here:

22. Do you take any natural supplements or vitamins?
YESNO

If YES, please list them here:

23. Do you have any allergies?
YESNO

If YES, please list them here:

24. Do you have any medical problems or diseases?
YESNO

If YES, please list them here:

25. Have you had an infections or a virus with a fever in the last 6 months?
YESNO

26. Have you ever had chemotherapy or radiotherapy for cancer?
YESNO

27. Do you suffer with an autoimmune disease such as lupus?
YESNO

If YES, please list them here:

28. Do you have a diagnosed thyroid gland problem?
YESNO

29. Do you suspect that you have a hormonal imbalance?
YESNO

If YES, what do you think it is?

30. Have you ever been diagnosed with any of the following?
Unexplained infertility YESNO
Polycystic ovarian syndrome YESNO
Excess male hormones YESNO

31. Do you get regular sunlight?
YESNO

32. Do you have very high stress levels?
YESNO

33. Have you had any blood tests to determine the cause of your hair loss? Please select from the list below:
Thyroid functionMale hormone (androgen) levelsOestrogen and progesterone levelsFSH levels (test for menopause)Autoimmune diseasesGluten intolerance = HLA DQ genotypeFull blood countSerum iron studiesInflammation in the whole body – ESR and CRP

FEMALE GYNAECOLOGICAL HISTORY

1. Have you gone through menopause?
YESNO

If YES, at what age?

2. Are your menstrual periods regular?
YESNO

If NO, how often do they come?

3. Are your menstrual periods heavy?
YESNO

4. Are you taking HRT?
YESNO

If YES, what type?

5. Are you taking the contraceptive pill or using another form of contraception?
YESNO

If YES, what type?

DIETARY HISTORY

1. Have you changed anything in your diet and lifestyle over the last 3 months?
YESNO

If YES, what?

2. Please tell us what you eat for the following meals on a typical day?
BREAKFAST:

LUNCH:

DINNER:

SNACKS:

How many alcoholic drinks daily?

How many cigarettes smoked daily?

How much water drunk daily?

3. How much do you weigh?

4. How tall are you?

5. If you could change anything about your hair, what would it be?