New Patient Intake Form Δ
Personal Information ZELDA HAIR CLINIC New Patient Intake Form
Complete your confidential intake form before your appointment.
Welcome to Zelda Hair Clinic! Please complete this confidential intake form before your appointment. The information you provide helps us better understand your health, hair, and wellness goals so we can provide the best possible care. Your information is kept private and secure.Your privacy matters to us. The information you provide is used only to prepare for your consultation and support your care. Please complete this form in a private setting and provide accurate information to the best of your knowledge.
Contact Information Address
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Emergency Contact
Employment
Referral Source How did you hear about Zelda Hair Clinic?
- Select - Google Search Google Maps Facebook Instagram Friend or Family Physician Referral Existing Patient Website Community Event Other
Appointment Reason What brings you to Zelda Hair Clinic today? (Select all that apply.)
Please briefly describe your primary concern.
Personal History & Lifestyle Understanding your daily life, stress levels, and environment helps us identify factors that may be affecting your overall wellness and hair health.
Marital & Family Information Marital Status
- Select - Single Married Divorced Widowed Separated Domestic Partnership Prefer not to say
Who lives in your household?
Physical Activity How often do you exercise?
Sleep Average Hours of Sleep Per Night
Do you wake feeling rested?
Additional Sleep Comments
Stress How do you typically manage stress?
Tobacco & Alcohol Do you currently smoke or use tobacco products?
Do you use recreational drugs?
Water Intake Approximately how much water do you drink each day?
- Select - Less than 2 cups 2–4 cups 5–8 cups More than 8 cups
Overall Health How would you rate your overall health?
Is there anything else about your lifestyle that you feel is important for us to know?
Current Health Concerns Help us understand your current health concerns and medical history so we can provide personalized care tailored to your needs.
Primary Health Concerns What are your primary health concerns today?
When did these concerns begin?
Which best describes your concerns?
Severity How severe are your symptoms?
Current Medical Care Are you currently under a physician's care?
Medications Are you currently taking prescription medications?
Please list all prescription medications, dosage, and reason for taking them.
Supplements Do you currently take vitamins or supplements?
List all vitamins, minerals, herbs, and nutritional supplements.
Allergies Do you have any known allergies?
Please list your allergies and reactions.
Previous Treatments Have you previously tried any of the following?
Please describe the treatments you've tried and whether they helped.
Family History Have any immediate family members experienced any of the following?
Please provide any additional family medical history you feel is important.
Previous Testing Have you had any recent blood work or laboratory testing?
Nutrition & Digestive Health Nutrition & Digestive Health Your diet and digestive health play a vital role in hair growth, scalp health, and overall wellness. Please answer the following questions as accurately as possible.
Eating Habits How many meals do you typically eat each day?
- How many meals a day - 1 2 3 4+ Varies
Which meals do you usually eat?
Do you eat breakfast regularly?
Do you prepare most of your meals at home?
Water & Beverages How much water do you drink daily?
- Select How Many Cups a Day - Less than 2 cups 2–4 cups 5–8 cups More than 8 cups
Which beverages do you drink regularly?
Dietary Preferences Do you follow a specific eating plan?
Food Sensitivities Do you have any food allergies or sensitivities?
Digestive Health Have you experienced any of the following digestive symptoms? (Select all that apply.)
How often do you have bowel movements?
Do you feel your digestion is healthy?
Nutritional Support Have you ever worked with a nutritionist, dietitian, or functional nutrition practitioner?
If yes, please describe the recommendations or treatment you received.
Goals What nutrition goals would you like help with?
Please tell us anything else about your diet or digestion that you think we should know.
Medical Conditions & Comprehensive Health History Please tell us about any past or current medical conditions. Select all that apply. If you choose any conditions, you can provide additional details below each section.
Gastrointestinal Have you ever been diagnosed with any of the following?
- Select - (IBS) Past (IBS) Now Crohn's Disease Past Crohn's Disease Now Ulcerative Colitis Past Ulcerative Colitis Now Gastritis / Peptic Ulcer Disease Past Gastritis / Peptic Ulcer Disease Now GERD / Acid Reflux Past GERD / Acid Reflux Now Celiac Disease Past Celiac Disease Now SIBO Past SIBO Now Gut Infections Past Gut Infections Now Dysbiosis Past Dysbiosis Now Leaky Gut Past Leaky Gut Now Food Allergies / Intolerances Past Food Allergies / Intolerances Now Gallstones Past Gallstones Now Absorption Issues Past Absorption Issues Now Other None of the Above
Please describe any gastrointestinal conditions, treatments, and approximate dates.
Cardiovascular
- Select - Heart Attack Past Heart Attack Now Heart Disease Past Heart Disease Now Stroke Past Stroke Now High Cholesterol Past High Cholesterol Now Irregular Heartbeat (Arrhythmia) Past Irregular Heartbeat (Arrhythmia) Now High Blood Pressure Past High Blood Pressure Now Rheumatic Fever Past Rheumatic Fever Now Mitral Valve Prolapse Past Mitral Valve Prolapse Now Other None of the Above
Hormones & Metabolic
- Select - Type 1 Diabetes Past Type 1 Diabetes Now Type 2 Diabetes Past Type 2 Diabetes Now Hypoglycemia Past Hypoglycemia Now Metabolic Syndrome Past Metabolic Syndrome Now Insulin Resistance / Prediabetes Past Insulin Resistance / Prediabetes Now Hypothyroidism Past Hypothyroidism Now Hyperthyroidism Past Hyperthyroidism Now Hashimoto's Disease Past Hashimoto's Disease Now Graves' Disease Past Graves' Disease Now Endocrine Disorder Past Endocrine Disorder Now PCOS Past PCOS Now Infertility Past Infertility Now Weight Gain Past Weight Gain Now Weight Loss Past Weight Loss Now Eating Disorder Past Eating Disorder Now Menopause Symptoms Past Menopause Symptoms Now Hair Loss Related to Hormones Past Hair Loss Related to Hormones Now Other None of the Above
Please provide additional details.
Cancer History
- Select - Breast Cancer Past Breast Cancer Now Colon Cancer Past Colon Cancer Now Lung Cancer Past Lung Cancer Now Ovarian Cancer Past Ovarian Cancer Now Prostate Cancer Past Prostate Cancer Now Melanoma Past Melanoma Now Other Skin Cancer Past Other Skin Cancer Now Other None of the Above
Please describe diagnosis dates and treatments.
Kidney & Urinary
- Select - Kidney Stones Past Kidney Stones Now Frequent UTIs Past Frequent UTIs Now Interstitial Cystitis Past Interstitial Cystitis Now Gout Past Gout Now Other None of the Above
Additional urinary or kidney information
Musculoskeletal
- Select - Arthritis Past Arthritis Now Arthritis Past Arthritis Now Rheumatoid Arthritis Past Rheumatoid Arthritis Now Fibromyalgia Past Fibromyalgia Now Osteoporosis Past Osteoporosis Now Chronic Back Pain Past Chronic Back Pain Now Joint Pain Past Joint Pain Now Muscle Pain Past Muscle Pain Now Other None of the Above
Additional musculoskeletal information
Respiratory
- Select - Asthma Past Asthma Now Chronic Sinusitis Past Chronic Sinusitis Now Bronchitis Past Bronchitis Now Emphysema Past Emphysema Now Pneumonia Past Pneumonia Now Sleep Apnea Past Sleep Apnea Now Frequent Colds Past Frequent Colds Now Other None
Additional respiratory information
Skin Conditions
- Select - Eczema Past Eczema Now Psoriasis Past Psoriasis Now Dermatitis Past Dermatitis Now Hives Past Hives Now Rash Past Rash Now Melanoma Past Melanoma Now Other Skin Cancer Past Other Skin Cancer Now Other None of the Above
Additional skin condition information
Neurological & Mental Health
- Select - Depression Past Depression Now Anxiety Past Anxiety Now Bipolar Disorder Past Bipolar Disorder Now Schizophrenia Past Schizophrenia Now ADHD Past ADHD Now Autism Spectrum Disorder Past Autism Spectrum Disorder Now Headaches Past Headaches Now Migraines Past Migraines Now Memory Problems Past Memory Problems Now Parkinson's Disease Past Parkinson's Disease Now Multiple Sclerosis Past Multiple Sclerosis Now ALS Past ALS Now Seizures Past Seizures Now Alzheimer's Disease Past Alzheimer's Disease Now Concussion / Traumatic Brain Injury Past Concussion / Traumatic Brain Injury Now Other None of the Above
Additional neurological or mental health information
Family Medical History Have any immediate family members been diagnosed with:
- Select Family Illness - Hair Loss Past Hair Loss Now Thyroid Disease Past Thyroid Disease Now Diabetes Past Diabetes Now High Blood Pressure Past High Blood Pressure Now Heart Disease Past Heart Disease Now Cancer Past Cancer Now Autoimmune Disease Past Autoimmune Disease Now Alopecia Past Alopecia Now Other None
Please describe any significant family medical history.
Additional Health Information Is there anything else about your medical history that you would like Dr. Zelda to know?
Environmental Exposure & Oral Health Your environment and oral health can significantly impact your overall wellness and hair health. Please answer the following questions as accurately as possible.
Environmental Exposure Have you been regularly exposed to any of the following? (Select all that apply.)
- Select Environmental Exposure - Mold or Mildew Past Mold or Mildew Now Cigarette Smoke Past Cigarette Smoke Now Secondhand Smoke Past Secondhand Smoke Now Pesticides Past Pesticides Now Herbicides Past Herbicides Now Household Chemicals Past Household Chemicals Now Industrial Chemicals Past Industrial Chemicals Now Heavy Metals Past Heavy Metals Now Lead Paint Past Lead Paint Now Asbestos Past Asbestos Now Air Pollution Past Air Pollution Now Well Water Past Well Water Now Contaminated Water Past Contaminated Water Now None of the Above Other
If Other, please describe
Have you ever worked in an environment with chemical exposure?
Please describe the workplace and the chemicals or materials you were exposed to.
Do you believe environmental factors may be affecting your health?
Oral & Dental Health How often do you brush your teeth?
What type of toothpaste do you primarily use?
- Select Toothpaste - Fluoride Fluoride-Free Natural Prescription Charcoal Other
Do you have mercury (silver) amalgam fillings?
Have any mercury fillings been removed?
If yes, please describe how and when they were removed.
Have you had any root canals?
When were the root canals performed?
Do you currently experience any of the following dental concerns?
Is there anything else about your oral or dental health that you would like Dr. Zelda to know?
Lifestyle & Sleep Your daily habits, stress levels, and sleep quality can have a significant impact on your overall wellness and hair health. Please answer the following questions as accurately as possible.
Eating & Lifestyle History Have you had periods of unhealthy eating habits?
Which of the following have you experienced? (Select all that apply.)
Please list any diets you have followed for a significant period of time.
Substance Use Have you ever used or regularly consumed any of the following?
- Select Consumption Level - Used Regularly Consumed Used Regularly Consumed Used Regularly Consumed Used Regularly Consumed Used Regularly Consumed Used Regularly Consumed Used Regularly Consumed None of the Above
Do you currently use any of the above?
If yes, please describe your current use.
Stress Management How well do you feel you manage stress?
What helps you manage stress?
Select up to 6 choices Exercise Prayer / Faith Meditation Reading Counseling / Therapy Family & Friends Hobbies Music Nature Other
Is there anything else you would like to share about your stress management?
Sleep Quality Are you satisfied with your sleep?
Do you stay awake during the day without dozing?
Are you usually asleep (or trying to sleep) between 2:00 AM and 4:00 AM?
Do you usually fall asleep within 30 minutes?
How many hours do you typically sleep each night?
- Select Sleep Level - Less than 4 4–5 6 7 8 More than 8
Which sleep issues do you experience? (Select all that apply.)
Please tell us anything else about your sleep that you think is important.
Energy Women's Health This section helps us better understand hormonal and reproductive factors that may affect your overall wellness and hair health.
Menstrual History Are you currently menstruating?
Are your menstrual cycles generally regular?
If irregular, please describe.
Have you experienced any of the following? (Select all that apply.)
Pregnancy History Have you experienced any of the following?
Additional pregnancy history (optional)
Menopause Have you gone through menopause?
Age menopause began (if known)
Are you experiencing any of the following?
Hormonal Therapy Are you currently taking hormone replacement therapy (HRT) or hormonal support supplements/herbs?
Please list the medications, supplements, or herbs you are taking.
Women's Health Conditions Have you ever been diagnosed with any of the following?
Please provide any additional information you feel is important regarding your reproductive or hormonal health.
Hair & Scalp Assessment This section helps Dr. Zelda better understand your hair history, scalp condition, and hair care routine before your consultation.
What is your primary hair concern?
Please describe your hair concern in your own words.
Approximately how long have you been experiencing this concern?
- Select Length of Time - Less than 1 Month 1–3 Months 3–6 Months 6–12 Months 1–2 Years More than 2 Years
Where are you noticing changes? (Select all that apply.)
Hair Type Hair Texture
- Select Hair Texture- Straight Wavy Curly Coily / Kinky
Hair Thickness
- Select Hair Thickness - Fine Medium Coarse
Hair Density
- Select Hair Density- Thin Average Thick Unsure
Do you currently experience any of the following?
How would you describe your scalp?
Please describe any scalp concerns.
Hair Care Routine How often do you wash your hair?
- Select How Often - Daily Every 2–3 Days Weekly Every Two Weeks Monthly Other
Which products do you regularly use?
Chemical & Styling History Have you used any of the following in the past 12 months?
Do you regularly wear any of the following styles?
Do you frequently wear tight hairstyles?
Hair Loss Treatments Have you previously tried any of the following?
Please describe what treatments you have tried and whether they helped.
Hair Goals What are your hair goals?
Describe what success would look like for you after treatment.
Hair Photos Upload Photos of Your Hair (Optional but Recommended) Please upload clear photos of:
Front Hairline
Left Side
Right Side
Top of Head
Back of Head
Is there anything else about your hair or scalp that you'd like Dr. Zelda to know before your appointment?
Goals, Consent & Signature Thank you for completing your intake form. Please review the following acknowledgments and provide your electronic signature before submitting your information.
Wellness Goals What are your primary goals? (Select all that apply.)
What would you like to achieve by working with Dr. Zelda?
Communication Preferences How may we contact you regarding appointments and your treatment plan?
Would you like to receive educational wellness tips, promotions, and clinic updates?
Patient Acknowledgment
I certify that the information provided in this intake form is complete and accurate to the best of my knowledge. I understand that providing inaccurate or incomplete information may affect my consultation and treatment recommendations.
Consent for Evaluation
I understand that Zelda Hair Clinic provides wellness, trichology, nutritional, and educational services. I understand these services are intended to support my overall health and are not a substitute for emergency medical care or treatment provided by my physician.
Privacy Notice
Your personal information will be used only for your care, appointment scheduling, clinic communications, and the maintenance of your confidential patient record. We are committed to protecting your privacy.
Do you give Zelda Hair Clinic permission to photograph your hair and scalp during treatment for medical documentation?
May before-and-after photos be used for educational or marketing purposes only after all identifying information has been removed?
Electronic Signature Click Submit Intake Form below.
After your form is submitted:
Your information will be securely sent to Zelda Hair Clinic.
Dr. Zelda will review your intake before your appointment.
If additional information is needed, our office will contact you.
Thank you for choosing Zelda Hair Clinic & Wellness Center .
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