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At Innovative Hair Designs salon, we go the extra mile to guarantee that we give our clients in Seattle, Washington the best in hair and scalp services. See to it that you receive the exact treatment you need. Complete our online form today!

Client Profile Form


Gender*
What is the problem you are experiencing? *
Symptoms Checklist
Where are you experiencing hair loss? *
Is the hair loss sudden with smooth, round bald patches appearing in less than three months?
Hair Loss-Approximately how much hair is left on your head? *
Have you experienced total hair loss on your face?
Have you experienced total hair loss on your body?
Is there a history of hair loss in your family? If so, which family member(s)? *
Your hair type *
Lifestyle
Your general health *
Do you exercise regularly?
Are you under constant pressure or stress?
How do you relax/relieve stress? *
Do you use hair extensions or weave?
Do you wear wigs or lace front regularly?
Have you plaited or braided your hair in the past five years?
Have you used bonding glue for your extensions?
Do you use clip-on extensions?
Do you wear ponytails regularly?
Do you have the following conditions? *
Hair Care Routine
Do you use chemicals on your hair, like bleach, perm solutions, hair colorings, and relaxers?
Your scalp *
Is there a crust buildup on your scalp?
Have you had a blood test in the last 12 months?
Medical Profile
Do you ever use sharp objects to scratch your while wearing braids or weaves?*
Do you take prescription medicines? *
Do you have an iron deficiency or any other form of dietary deficiency?
Do you have an allergy to caffeine? *
Do you have any other allergies?
Are you allergic to latex?
Does your skin heal normally?
Does your skin keloid?
Are you presently under a doctor's care?
Have you used any medication or treatment in the past for hair loss or scalp conditions? *
Treatments
How long? *
How did it work? *
Were you using any other hair loss treatments at the same time?
Have you received any treatment advice recently? If so, by whom? *
What form of contraception do you use, if any? *
Have you recently given birth?
Do you breastfeed?
Have you or anyone in your immediate family suffered from breast cancer?
Are you currently pregnant?
Will you be trying for a child in the next 12 months?
Have you had a raised temperature/fever due to illness in the last 3-6 months?
Dietary Habits- What type of diet do you have? *
Do you take any mineral or vitamin supplements?
Has your weight changed dramatically in the last 12 months? *
Have you had any form of Gastro bypass, lap band, sleeve, etc.?
Please check the box before submitting the form.
By clicking submit, I hereby state that all my answers to the above questions are true as to the best of my knowledge.
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