True You
Health
Home
Book Online
Women of Color
Weight Loss
Hair Assessment Survey
First Name
Last Name
Email
Phone
Privacy Policy
Gender
Female
Male
Timeframe
<3 months
3–6 months
6–12 months
1–3 years
> 3 years
Condition
Shedding
Thinning
Bald patches
Receding hairline
Breakage
Shortened hair strands
Loss of volume
Location
Crown (top of head)
Front Hairline
Left Side
Right Side
Back of Scalp
All Over
Hair loss
Sudden
Gradual
Cyclical
Symptoms
Itching
Burning
Tenderness
Flaking/dandruff
Redness
Pain
Hairstyles
Loose.natural
Braids
Weaves/extensions
Wigs
Tight ponytails/buns
Chemical relaxers
Heat styling
Use
Oils
Serum
Medicated shampoos
Supplements
History
Thyroid
PCOS
Autoimmune disease
Anemia/ low iron
Vitamin deficiencies
Hormonal imbalance
Recent illness or surgery
Medications
Birth control/HRT use
Recent medication changes
Weight loss medication
Life Event
Pregnancy/postpartum
Significant weight loss
High stress
Illness (including COVD)
Surgery
Prior Treatment
Minoxidil
PRP
Steroid Injection
Prescription medications
Supplements
None
Family
Hair thinning in family
Baldness (male or female relatives)
Unknown
Stress
Low
Moderate
High
Sleep
<5hours
5-7 hours
7+hours
Diet
Balanced
Restrictive
High Protein
Vegan/Vegetarian
Goals
Regrow Hair
Stop Shedding
Improve thickness
Restore hairline
Improve scalp health