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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

Date Of Birth
Day
Month
Year
Sex
Male
Female
Prefer not to say
Any illness?
Are you on any supplement?
Yes
No
Are you undergoing weight loss programme such dieting , manjaro, etc ?
Yes
No
Which of these describe your hair?
Where are you losing your hair?
Which of the following symptoms are you experiencing
Do you have family history of hair loss?
Yes
No
Have you seen any healthcare profession before? For example, dermatologists, Trichologist, or doctors
Yes
No
Do you already have a diagnosis?
Yes
No
Have you experienced any significant health conditions?
Yes
No
Have you undergone medical treatments recently?
Yes
No
Does anyone in your immediate family have a history of hair or scalp issues?
Yes
No
Are you under current significant stress?
Yes
No
Do you frequently use heat styling tools?
Yes
No
Would you say your symptoms get worse or better when you are under stress?
Worse
Better
Same
Do you consume a balanced diet that includes fruit and vegetables?
Yes
No
Do you have any of the following deficiencies ? Tick "No" if you dont have
Have you given birth within the last 6 months?
Yes
No
Do you drink alcohol ?
Yes
No
Do you smoke?
Yes
No
Do you apply oils on the scalp ?
Yes
No
Do yo have any allergies or intolerances? please select all that apply. If none apply please go to next question
I accept terms & conditions

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