Tóc Ký™ Survey – Hair health assessment

Part 01

Personal Information

Full name*

Phone number*

Age*

Gender*

Women

Men

Other

Part 02

Current Hair & Scalp Condition

What is your main concern about your hair? (you can choose several)

More hair loss than usual

Thinning, reduced density

Receding hairline / patchy baldness

Weak, brittle hair, split ends

Itchy scalp, dandruff, inflammation

Slow growth, new hair thin and weak

Want to improve overall hair health

When did the hair loss begin?

< 3 months

3–6 months

6–12 months

1–3 years

> 3 years

What pattern of hair loss have you noticed?

Even shedding all over (diffuse)

Thinning along the parting, middle of the head

Receding temples / forehead

Balding crown

Patchy hair loss (alopecia areata)

Pattern not yet clear

On average, how many hairs do you see falling out each day? (estimate when brushing / washing)

< 50

50–100

100–150

> 150

Don't know

What is your scalp's current condition? (you can choose several)

Normal

Very oily / greasy

Dry, flaky

Often itchy

Dandruff

Red, inflamed / rashy scalp

Part 03

History & Medical Factors

Does anyone in your family have baldness / early hair loss?

Yes, father's side

Yes, mother's side

Yes, both

None

Don't know

Do you have, or have you been diagnosed with, any of the following? (you can choose several)

This information helps the medical team identify systemic causes affecting the hair cycle and choose the safest protocol for you.

Hypothyroidism / Hyperthyroidism (thyroid disorder)

Polycystic ovary syndrome (PCOS)

Anaemia / Low ferritin

Diabetes

Lupus / Autoimmune disease

Scalp psoriasis

No related conditions

Other (please specify below)

Are you taking any medication? In particular: contraceptives, long-term antibiotics, blood pressure medication, retinoids, psychiatric medication; please specify if so

Are you currently in, or have you recently been through, any of the following? (you can choose several)

Postpartum (within 12 months)

Breastfeeding

Perimenopause / Postmenopause

Recent cancer treatment / chemo or radiotherapy

Major surgery / serious illness in the past 6 months

None

Have you had any tests related to hair loss? (ferritin, vitamin D, hormones...)

Tested, normal

Tested, abnormal

Not tested

Part 04

Stress, Sleep & Lifestyle

Your stress level over the past 6 months?

No stressExtremely stressed

On average, how many hours do you sleep each night?

< 5 hours

5–6 hours

7–8 hours

> 8 hours

Your sleep quality?

Good, deep sleep

Average

Poor, often sleepless

Your diet?

Complete and varied

Dieting / significantly restricting calories

Vegan / little animal protein

Irregular, often skip meals

Are you taking any hair-related vitamins / supplements?

Yes

None

If yes, please specify:

Part 05

Hair Care Habits

How many times a week do you wash your hair?

1–2 times

3–4 times

5–6 times

Every day

Do you regularly use heat on your hair? (hot hairdryer, straightener, curler...)

Rarely / Never

1–2 times / week

Almost every day

Do you dye, perm or have keratin treatments?

None

Occasionally

Regularly

Have you had hair loss / hair restoration treatment anywhere before?

No, this is the first time I've looked into it

Used home hair products / serums

Treated at another spa or clinic

Had a hair transplant

Part 06

Goals & Notes

What is your main goal after treatment?

Significantly reduce hair loss

Stimulate new growth, increase density

Improve scalp health (itching, dandruff, inflammation)

Maintain and strengthen results after a hair transplant

Complete restoration, several goals combined

What kind of protocol do you prefer?

Completely non-invasive (devices, topical)

Open to gentle micro-infusion (shallow needle-free, painless)

Want maximum effect, including meso/cellular therapy

No preference yet; I'd like the team's advice

Is there anything else you'd like the Claire team to know before your consultation?

How did you hear about Claire's Hair Restoration service?

Instagram

Friends / family

Already a Claire client

Google

Other

Your information is encrypted and only shared with Claire's medical team for your consultation. After you submit, we'll contact you within 24 hours to arrange a suitable appointment.

Back to Hair Restoration

Tóc Ký™ Hair Record

Tóc Ký™
Hair Health Record

Personal Information

Current Hair & Scalp Condition

History & Medical Factors

Stress, Sleep & Lifestyle

Hair Care Habits

Goals & Notes

Thank You
For Sharing

Tóc Ký™ Hair Record

Tóc Ký™Hair Health Record

Personal Information

Current Hair & Scalp Condition

History & Medical Factors

Stress, Sleep & Lifestyle

Hair Care Habits

Goals & Notes

Thank YouFor Sharing

Tóc Ký™
Hair Health Record

Thank You
For Sharing