Hair Restoration

**1-Month Hair Restoration Treatment Plan**

My personalized 1-month hair restoration program is designed to support healthier hair growth, improve scalp health, and help reduce hair thinning and shedding. Each treatment plan is tailored to the client’s individual hair and scalp needs and may include a combination of professional scalp treatments, hair-growth support therapies, nutritional guidance, and a customized at-home care routine.

**What’s included:**

* Personalized scalp and hair assessment
* Professional hair/scalp restoration treatments
* Customized 30-day treatment plan
* Guidance on hair-care and scalp maintenance
* At-home regimen recommendations
* Progress monitoring and follow-up

The goal is to create a healthier scalp environment and support stronger, fuller-looking hair with consistent care over the 30-day program.

# Hair Restoration Pre-Appointment Questionnaire

Please complete this short questionnaire before your appointment. Your answers will help us personalize your 1-month hair restoration plan.

### 1. What is your main hair concern?

☐ Hair thinning
☐ Hair shedding
☐ Receding hairline
☐ Thinning crown
☐ Patchy hair loss
☐ Breakage
☐ Scalp concerns
☐ Other

### 2. When did you first notice changes in your hair?

[Answer]

### 3. Do you currently have any scalp concerns?

☐ Itching
☐ Flaking
☐ Irritation
☐ Tenderness
☐ None
☐ Other

### 4. Have you tried any hair-loss or hair-growth treatments before?

☐ Yes
☐ No

If yes, what have you tried?
[Answer]

### 5. Are you currently taking any medications, vitamins, or supplements?

☐ Yes
☐ No

If yes, please list them.
[Answer]

### 6. Have you experienced any major illness, surgery, significant stress, pregnancy/postpartum changes, or major weight loss within the past year?

☐ Yes
☐ No

If yes, please provide details.
[Answer]

### 7. What is your primary hair restoration goal?

☐ Reduce shedding
☐ Support hair growth
☐ Improve fullness
☐ Improve scalp health
☐ Strengthen existing hair
☐ Other

### 8. What would you like us to focus on during your 1-month program?

[Answer]

### 9. Please upload current photos of your hair/scalp.

☐ Front
☐ Left side
☐ Right side
☐ Top/crown
☐ Back

### 10. Full Name

[Answer]

### 11. Appointment Date

[Date]