amy walsh

Phone Number

Email

Age

Occupation

General health

Health Changes

Procedures in the last 12 months

Family medical history

Medication/Supplements

Products / Routine

How often do they wash their hair?

Reaction to any brands

Description of situation

Main Concern

Appearance/Symptoms

First noticed

Ever been diagnosed with a scalp condition?

If yes please specify

Do they have colour in their hair?

Have they ever been pregnant?

If yes, how long ago?

Allergies

If yes then please specify

What is their current diet like?

How did they hear about us?

Imagery

Front facing

Left side

Right side

Area of concern