Headlines Trichology 

Salon & Spa

Reduce Hair Loss and Other Hair Problems

Headlines Trichology Salon & Spa in Houston, Texas provides holistic services to treat a wide range of hair and scalp problems. 

346-212-0518

Providing Solutions to Your Hair and Scalp Problems 

Headlines Trichology Salon & Spa in Houston, Texas provides holistic services to treat a wide range of hair and scalp problems.

Book an Appointment

Hair Loss Consultation Form

Date
Sex*
How did you hear about us?
Is the hair sudden with smooth round patches appearing in less than 3 months?*
Have you experienced total hair loss on your face?*
Have you experienced total hair loss on your body?*
How is your general health?
Do you exercise regularly?*
Are you under constant pressure or stress?*
Hairstyle *
Do you use hair extensions- weave?
Do you wear wigs / lace front regularly?*
Have you platted or braided your hair in the past 5 years?*
Have you used blonde glue for your extensions?*
Do you use clip on extensions?*
Do you wear a ponytail regularly?*
Do you every use a sharp object to scratch your scalp while wearing braids or weave?*
How often do you shampoo your hair?
Do you use chemical on your hair?*
What scalp problems do you have?
Is there a crust build up on your scalp?*
Medical Problems *
Have you had blood test in the last 12 months?
Do you have the following conditions?*
Do you take prescription medicines?*
Do you have an iron or dietary deficiency?*
Do you have allergy to caffeine?*
Do you have any other allergies?*
Are you allergic to latex?*
Does your skin heal normally?*
Does your skin Keloid?*
Are presently under a doctor’s care?*
Have you used any medication or treatments for your hair loss or scalp conditions in the past?*
How long?*
Were you using any other hair treatment at the same time?*
Have you recently given birth?*
Do you breast feed now or any time breast fed?*
Have you or any of your immediate family suffered from breast cancer?*
Are you currently pregnant?*
Will you be trying to have a child in the next 12 months?*
Have you had a raised temperature/ fever due to illness in the last 3-6 months?*
Do you consistently experience any of the following?*
Do you smoke?*
What type of diet do you have?
Do you take any mineral or vitamin supplements?*
Have you had any form of Gastro Bypass, Lap Band, and Sleeve? (etc.)*
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Kids Client Profile

Personal-Confidential

Please fill out completely

Personal Confidential Please fill out complete
Early Detection will always be the best defense for anyone experience hair loss or scalp disorders, Headlines Hair clinic is here to assist you.
How did you hear about HTS&S?
Is the problem you are experience?*
Are you experiencing hair loss?*
Is the hair sudden with smooth round patches appearing in less than 3 months?*
Approximately how much hair are you left with on the head?*
Have you experienced total hair loss on your body?
Is there history of hair loss in your family? If so, which family members?*
What’s your hair type?*
Life Style*
Is your general Health:
Do you exercise regularly?*
Are you under constant pressure or stress?*
How do you relax / relieve stress?*
Hairstyle*
Do you use hair extensions- weave?
Have you platted or braided your hair in the past 5 years?*
Do you wear ponytails regularly?*
HAIR CARE ROUTINE*
How often do you shampoo your hair?
Do you use chemical on your hair? *
SCALP PROBLEMS
Is your Scalp?
Does your scalp weep?*
Is there a crust build up on your scalp?*
MEDICAL PROBLEMS*
Have you had blood test in the last 12months?
Do you have the following conditions?*
Do you take prescriptions medicines?*
Do you have an iron deficiency, or any other form of dietary deficiency?*
Do you have allergy to caffeine?*
Do you have any other allergies?*
Are you allergic to latex?*
Does your skin heal normally?*
Does your skin Keloid?*
Are presently under a doctor’s care?*
Have you used any medication or treatments for your hair loss or scalp conditions in the past?*
How Long?*
How did it Work?*
Where you using any other hair treatment at the same time?*
Have you received any treatment advice recently? If so, by whom?*
Have you had a raised temperature/ fever due to illness in the last 3-6 months?*
Do you consistently experience any of the following?*
How would you describe the appearance of your fingernails?
DIETARY HABITS
What type of diet do you have?
Breakfast:
Lunch:
Dinner:
Snack:
Do you take any mineral or vitamin supplements?*
Has your weight changed dramatically in the last 12 months?*
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Kids Hair Loss Consultation Full Work-Up: $100.00

Your consultation may take approximately 1 hour. We complete a comprehensive report on your individual questionnaire responses. Emphasis is on identifying and eliminating the causes of the problem and providing nutritional advice that is deemed appropriate. You will receive a detailed report that will provide full explanation to your responses. 


If this report indicates that specific pathology testing is needed, you need blood work from your family doctor. A follow-up appointment is given for results of all information. Upon receipt of your results of the pathology testing done by your family doctor, we may better determine what is influencing your problem. Consultation includes:

  • Medical History
  • Dietary Evaluation
  • Lifestyle Analysis
  • Digital photo may be taken for hair loss progressive assessments (the face will not be shown)
  • A microscopic analysis of your hair and scalp
  • An in-depth consultation about your body systems deficiencies
  • A recommended program to help balance the body
  • A treatment plan at home with regular reassessment to check the progress, and long-term management

Click here for a copy of the kids consultation form. Once completed, please submit it to [email protected]

Privacy Act Statement

Your privacy is important to Headlines Trichology Salon & Spa. This privacy statement provides information about the personal information that HTS&S collects, and the ways in which HTS&S uses that personal information.


Headlines Trichology Salon & Spa may collect information that you provide for the sole purpose of consultation, diagnostic and treatment of scalp, hair, and health issues. HTS&S will take reasonable technical and organizational precautions to prevent the loss, misuse or alteration of your personal information. Your personal information will not be shared with anyone else without your permission.

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