Online Consultation 1Intro2Personal Details3Hair Loss4Hair/Scalp5Medical6Past Treatment7Diet8Comments9Photos 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 Australia 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 New Zealand. 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 0800 424 252. 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* Mr Mrs Miss Ms Name* First Surname Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Enter Email Confirm Email Home Phone*Work PhoneMobile*Occupation Sex* Female Male How did you hear about Advanced Hair Studio?*Please selectGoogle AdTVNZCH 1 late nightCH 2 late nightSKYSocial Media (Facebook, Twitter, Youtube)Brand ReputationReferralGoogle SearchOtherPlease specify 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 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 No Have you experienced total hair loss on your face? Yes No Have you experienced total hair loss on your body? Yes No 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) Afrian Asian Is your general health and fitness:Very goodGoodSatisfactoryPoorVery poorAre you under constant pressure or stress? Yes No Do you work in an environment that exposes you to chemicals on a daily basis? Yes No Have you plaited or braided your hair in the past 5 years? Yes No Do you use extensions or a weave-on? Yes No Do you plait or braid your hair? Yes No 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 No Which ones? How often Is your scalp: Flaky? Itchy? Dry? Oily? Normal? Have spots or acne? Prone to Dandruff Does your scalp weep? Yes No Is there a crust build up on your scalp? Yes No 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 No Please give details of the treatment:Do you take any prescription medicines? Yes No Please give details of medicine and expected duration:Do you have an iron deficiency, or any other form of dietary deficiency? Yes No Unsure Please give details of the deficiency:Do you have an allergy to lactose? Yes No Do you have an allergy to caffeine? Yes No Do you have any other allergies? Yes No Please give details of your allergies:What form of contraception do you use, if any? The Pill Barrier Contraceptives (ie condoms) Dianette Other If otherHave you recently given birth? Yes No Do you breast feed? Yes No Have you, or anyone in your immediate family suffered from breast cancer? Yes No Please give details:Are you, or is your partner currently pregnant? Yes No Will you be trying for a child in the next 12 months? Yes No Have you had a raised temperature/fever due to illness in the last 3-6 months? Yes No Do you give blood (are you a blood donor)? Yes No If you have used any of the treatments listed below for hair loss or a scalp problem please let us know:Nourkrin Yes No 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 No What was the name of the treatment? Procerin Yes No 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 No What was the name of the treatment? Provillus Yes No 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 No What was the name of the treatment? Revivogen Yes No 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 No What was the name of the treatment? Regaine Liquid Yes No 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 No What was the name of the treatment? Regaine Foam Yes No 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 No What was the name of the treatment? Propecia Yes No 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 No What was the name of the treatment? TRX2 Yes No 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 No What was the name of the treatment? Kérastase Densifique Yes No 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 No What was the name of the treatment? Were you using any other treatments Yes No 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 No 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 No 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) Do you take any mineral or vitamin supplements? Yes No 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 Select files Accepted file types: jpg, jpeg, pdf, gif, png, Max. file size: 128 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 contactcentre@advancedhair.com.au 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.
