Junons World Confidential Consultation Form

Consultation Questionnaire

1. When did you notice hair loss?

2. What type of hair loss do you have?

3. Type of hair loss:

4. Have you received any previous treatments or services for your hair loss?

Did you see any results?

5. What is your current hair state?

6. Has your hair been previously colored?

7. Does your hair loss affect your self-image? Do you avoid social situations due to hair loss?

8. Has anyone commented/noticed your hair loss?

9. Are you on medication?

If yes, please explain:

10. Are you allergic to anything?

11. Do you have a medical history we should be made aware of that may have contributed to your hair loss?

If yes, please explain:

12. How did you hear about Junons World?