Intake Form | Trinity Amour Beauty

top of page

Trinity Amour

Home
Intake Form
Shop
Contact
More

Use tab to navigate through the menu items.

Book Online

Client Intake Form

Hair / Scalp Recovery Consultation

First Name

Last name

Birthday

Month

Day

Year

Occupation

How did you hear about us?

Your Hair Story

What concerns or symptoms led you here today?

What are your hair goals or hopes?

How long have you noticed changes in your hair or scalp?

Family History & Hormonal Profile

Does hair loss run in your family? If yes, who is affected?

Do you have children? If yes, list ages:

Menopausal status

Not yet

Menopausal

Post-menopausal

Unsure

Are you currently using Hormone Replacement Therapy? If yes, type and duration:

Health, Medication & Lab Work

Are you currently undergoing medical treatment?

Hospitalizations in the last year? Reason:

Recent vaccinations (last 3–5 years):

Current medications and supplements (include dosage):

Any autoimmune or hormonal conditions?

Recent lab work (CBC, CMP, Thyroid, Ferritin, Vitamin D, etc.):

Lifestyle Snapshot

Water intake

Low

Moderate

High

Sleep pattern

Low

Moderate

High

Diet style

Balanced

Restrictive

Inconsistent

Other

Exercise frequency:

Stress level (1–10)

Recent major stress, illness, surgery, childbirth, or weight change:

Alcohol or tobacco use:

Hair Care & Styling History

How often do you shampoo?

Long answer

What shampoo and conditioner brands do you use?

Do you oil your scalp? Frequency and product used:

Previous chemical services (Relaxer, Color, Keratin, etc.):

History of tight styles (Braids, Ponytails, Extensions):

Do you blow dry or use heat regularly?

History of scalp trauma?

Shedding & Thinning Details

How would you describe your level of shedding or thinning?

Is the hair loss getting worse?

Do you feel styling practices contributed? If yes, explain:

What are you hoping to achieve from this consultation?

Additional notes or concerns:

Consultation Goals & Expectations

Acknowledgement & Consent

I confirm the information provided is accurate to the best of my knowledge.

Consent to before/after photos for documentation

Yes

Consent to scalp imaging and documentation

Yes

Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Contact Me

2718 N Belt Line Rd #25, Sunnyvale, TX 75182

Mail: trinityabeauty@gmail.com

Tel: 469.655.1615

bottom of page