Online Consultation

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1Intro

2Personal Details

3Hair Loss

4Hair/Scalp

5Medical

6Past Treatment

7Diet

8Comments

9Photos

Advanced Hair’s online consultation provides our hair loss specialists, and AHS In house Trichologists (Hair Loss Dr’s), with all of the information required to diagnose your hair loss condition and recommend an effective course of treatment for home-use. We can send a home-use treatment course anywhere in South Africa and most of the world and the form should take no longer than 10 minutes to complete. At the end you will be asked to upload photos of your hair loss. This is not compulsory but we ask that you upload photos if you have any available or are able to take some now.

A.H.S have clinics right around South Africa. We recommend you visit for a free one-to-one consultation with a hair loss specialist at any of these locations. To arrange this please call 0860 62 72 82. We are open 6 days a week including late nights.

Following submission of the form, we aim to get back to you the same day, but on weekends it may take up to 48 hours. Please ensure you answer all of the questions accurately.

Title*

Mrs

Miss

Name*

First Surname

Address*

Street Address Address Line 2 City Province ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Home Phone*

Work Phone

Mobile*

Occupation

Sex*

Female

Male

How did you hear about Advanced Hair Studio?*

Is the problem you are experiencing

Hair Loss

Scalp Problem

Are you experiencing hair loss:

On the top of your head only

On the top and sides of your head (all over scalp)

At the front (receding hairline)

At the back/vertex area

Hair loss sudden, in small round bald patches appearing in less than 3 months

Other

How long have you suffered with hair loss or thinning?

5 years or more

Between 2 and 5 years

Between 1 and 2 years

Less than 1 year

Approximately how much hair are you left with on the head?

Under 25%

25% - 50%

50% - 75%

More than 75%

Approximately how much hair are you left with in the affected areas?

Under 25%

25% - 50%

50% - 75%

More than 75%

Have you experienced total hair loss on your head?

Yes

Have you experienced total hair loss on your face?

Yes

Have you experienced total hair loss on your body?

Yes

Is there a history of hair loss in your family? If so, which family member(s)?

Father

Mother

Grandparents

Uncle

Brother or sister

Is your hair type:

Caucasian (white)

African

Asian

Other

Is your general health and fitness:

Are you under constant pressure or stress?

Yes

Do you work in an environment that exposes you to chemicals on a daily basis?

Yes

Have you plaited or braided your hair in the past 5 years?

Yes

Do you use extensions or a weave-on?

Yes

Do you plait or braid your hair?

Yes

How often do you wash your hair?

Do you use chemicals on your hair? e.g. bleach, perm solutions, hair colourings, relaxers or any other.

Yes

Which ones?

How often

Is your scalp:

Flaky?

Itchy?

Dry?

Oily?

Normal?

Have spots or acne?

Prone to Dandruff

Does your scalp weep?

Yes

Is there a crust build up on your scalp?

Yes

Please describe any other skin problems on your body or face.

Do you have any of the following conditions?

Anaemia

Crohn's Disease

Depression

Diabetes

Endometriosis

Gynecomastia

HIV

Hepatitis B

Hormone Imbalance

Hypertension (High Blood Pressure)

Hypotension (Low Blood Pressure)

Liver Problems

Migraine

Pheochromocytoma

Polycistic Ovarian Syndrome

Porphyria

Prostate Cancer

Prostate Problems

Renal Failure

Thyroid Problems

Other conditions, or expand on previous answers:

Are you currently having treatment by chemotherapy and/or radiation therapy?

Yes

Please give details of the treatment:

Do you take any prescription medicines?

Yes

Please give details of medicine and expected duration:

Do you have an iron deficiency, or any other form of dietary deficiency?

Yes

Unsure

Please give details of the deficiency:

Do you have an allergy to lactose?

Yes

Do you have an allergy to caffeine?

Yes

Do you have any other allergies?

Yes

Please give details of your allergies:

What form of contraception do you use, if any?

The Pill

Barrier Contraceptives (ie condoms)

Dianette

Other

If other

Have you recently given birth?

Yes

Do you breast feed?

Yes

Have you, or anyone in your immediate family suffered from breast cancer?

Yes

Please give details:

Are you, or is your partner currently pregnant?

Yes

Will you be trying for a child in the next 12 months?

Yes

Have you had a raised temperature/fever due to illness in the last 3-6 months?

Yes

Do you give blood (are you a blood donor)?

Yes

If you have used any of the treatments listed below for hair loss or a scalp problem please let us know:

Nourkrin

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Procerin

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Provillus

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Revivogen

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Regaine Liquid

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Regaine Foam

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Propecia

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

TRX2

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Kérastase Densifique

Yes

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other hair loss treatments at the same time?

Yes

What was the name of the treatment?

Were you using any other treatments

Yes

Name

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other treatments

Yes

Name:

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Were you using any other treatments

Yes

Name:

How long for?

0-3 months

4-7 months

More than 7 months

How did it work?

Thickened the hair a lot

Thickened the hair a bit

Stopped my hairloss

Slowed my hairloss

Did not work at all

Have you received treatment or advice from:

Trichologist

Hairdresser

Dermatologist

G.P.

Other

If other:

If yes, what advice?

What type of diet do you have?

Mixed Diet

Lacto Vegetarian (milk, cheese and vegetarian diet)

Pescatarian Diet (fish and vegetarian diet)

Vegan (purely vegetarian)

Other

Do you take any mineral or vitamin supplements?

Yes

If 'yes':

Has your weight changed dramatically in the last 12 months?

Weight Loss

Weight Gain

No Dramatic Weight Change

How many kgs / Lbs, over how long?

If you have any extra comments about your hair loss or scalp problem, please inform us in the space provided:

Photo Upload

Drop files here or

Accepted file types: jpg, jpeg, pdf, gif, png, Max. file size: 256 MB.

We request that you provide us with photos of your hair loss. Please refer to the photo examples underneath for a guide to taking the photos. If you do not have photos then you can complete the form without uploading by pressing the ‘complete form’ button below. We do ask that you provide us with photos – you can alternatively email to [email protected] after you have submitted the form. Please make sure you provide your name in the subject line.

Please confirm the following to complete the consultation:*

I accept

I agree that all information that I have given is true to the best of my knowledge and that I have not withheld information that could potentially be deemed relevant to a doctor's decision to prescribe medicines for hair loss. I agree that only I, the named patient completing this questionnaire, will take any medicines that I may be prescribed following submission of this form. I agree, prior to taking any medicines that may be prescribed, to read the patient information leaflet supplied with the medicines, and adhere to the instructions that accompany the medicines that I am requesting. I understand that there is a small chance of side effects that can occur from the hair loss medications offered by Advanced Hair Studio. The most common or relevant side effects related to the medicine or medicines that are prescribed to me should be explained by the adviser that contacts me, but should I have any further queries I will ask. I agree to notify Advanced Hair Studio if any side effects occur.

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