Pre-Consultation Form

Please complete the pre-consultation form prior to attending your consultation appointment.

Note: If you want a report after the consultation, it will incur £120. This will take about 2 weeks to be made.

Trinity Trichology Clinic

33, Down Way, Northolt, UB5 6PG

Phone

07956 293 093

Email

belinda.akobel@gmail.com

First name

Last name

Email

Whatsapp/Phone Number

Date Of Birth

Day

Month

Year

Address

Occupation

How long have you worked in this position?

Sex

Male

Female

Prefer not to say

Other (specify)

List your medication List (max. 6)

List Previous Medication

Are you on any supplement?

Yes

No

If yes , list them

Are you undergoing weight loss programme such dieting , manjaro, etc ?

Yes

No

Other (specify)

How long has this condition been?

Other (specify)

Have you seen any healthcare profession before? For example, dermatologists, Trichologist, or doctors

Yes

No

Do you already have a diagnosis?

Yes

No

If yes, name of diagnosis

Have you had any previous Hair loss Treatments (names of treatment and year )

Dr/GP Name

GP/ Dr's Address

Medical History (food, medication, known deficiencies e.g. iron, vitamin D, allergies, intolerances, thyroid) Please give details

When was the last time you had a blood test?

Have you given birth within the last 6 months?

Yes

No

List of Medications - Including contraceptives

Are you currently receiving any medical attention? Give details if applicable.

Have you had any operations in the last 3 years? Give details if applicable.

Please give a brief description of when and how your hair started thinning/shedding/breaking.

Upload a picture of the back of your hair

Upload a picture of the front of your hair

Upload a picture of the left side of your hair

Upload a picture of the right side of your hair

I accept terms & conditions

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