NTTI Client Consultation

Client Consultation

NTTI • Confidential

Office and enrollment details

Client completesClient fills in their name and date of consultation. Student fields are marked below.

Client ID #

Office DateInitials

Student First NameStudent

Student Last NameStudent

Client First NameClient

Client Last NameClient

Date of ConsultationClientEnrollment Month & YearStudent

Quarter Consultation SubmittedStudent

Client Profile

NTTI • Confidential

Contact and personal information

Client completesClient completes every field in black ink.

Full Name

Date

Date of BirthAge

Weight

Occupation

Home Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

May we contact you via email?

Email Address

Emergency Contact

Emergency Contact Name

Relationship

Home Phone

Cell Phone

Work Phone

Primary Care Physician

PCP Name

PCP Phone

PCP Address

Marital Status

If we cannot contact you, may we speak with your spouse or significant other about your treatment? Providing details below grants permission.

Spouse / Significant Other Name

Home Phone

Cell Phone

Work Phone

If someone referred you, please list referral

Student Consultation NotesBlue for observations · Red to address · Yellow to research

Social History

NTTI • Confidential

Client completesClient answers every question in black ink.

What level of education did you complete?

Did you serve in the armed forces?

Do you have children?

Do you have pets?

Have you traveled in a foreign country in the last year?

Hobbies

How often do you swim?

Social

I have completed my family.I have used steroids in the past for athletic purposes.

Habits

Cigarettes / cigars per day

Alcoholic beverages per week

Caffeine uses per day

Exercise days per week

Student Consultation NotesBlue for observations · Red to address · Yellow to research

Patient Questionnaire

NTTI • Confidential

Hair and scalp history

Client completesClient answers all hair, product and medication history, then signs.

When did your hair loss issue start?

Which styling implements do you use at home?

How often do you visit a Salon or Barber Shop?

What beauty services do you usually require?

When was your last visit?

What chemical services did you receive (relaxer, color, permanent wave)?

Was your hair damaged at home?

Ever lost hair from braiding/weaving?

Has your hair been over/under processed from chemicals or hair color?

Explain what you think happened to your hair or scalp

Do you do any hair care services at home?

How often do you shampoo your hair at home?

List any chemicals you use at home

Product brands in use

Shampoo

Conditioner

Hair Spray

Scalp Oil

Have you ever had your hair and scalp scanned or analyzed?

Have you received any hair implants, grafts, or PRP injections?

Have you ever had a Compass Body Scan?

Do you know your blood type?

Have you experienced any health problems?

List all vitamins currently taking and the purpose

Who recommended the vitamins?

List all herbs currently taking and the purpose

Who recommended the herbs?

List all medications currently taking

Do you have any drug or food allergies?

Have you had any reactions from any hair products?

Client Signature — Patient Questionnaire

Choose signature style

Signature preview

Date

Student Consultation NotesBlue for observations · Red to address · Yellow to research

HIPAA Information & Consent

NTTI • Confidential

Client completesClient prints name, signs and dates.

This Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services.

Patient information will be kept confidential except as necessary to provide services or handle administrative matters related to your care, including sharing with other healthcare providers, laboratories, and insurance payers.
It is the policy of this office to remind patients of their appointments by telephone, email, U.S. mail, or any convenient means. We may also send communications about changes to office policy or new technology.
Vendors used in the conduct of business may have access to PHI but must agree to abide by HIPAA confidentiality rules.
You agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the office manager or the doctor.
Your confidential information will not be used for marketing or advertising of products, goods, or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete, or modify any of these provisions to better serve the needs of the practice and the patient.
You have the right to request restrictions in the use of your protected information; however, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Print Name

HIPAA Consent Signature

Choose signature style

Signature preview

Date

Waiver & Release

NTTI • Confidential

Trichology Hair Service Release Waiver Form

Client completesClient signs and dates; trichologist counter-signs.

I (Client Name)

Trichologist Name

I, ____________, authorize and release the National Trichology Training Institute from any pre-existing hair loss problems as it relates to my hair loss and scalp disorders. I further release NTTI from any lawsuits or claims that come as it relates to any services that I may receive. NTTI has my permission to receive any information necessary from my previous stylist and medical professional either to myself or to ____________ (Trichologist) who accepts me as a client.

I authorize information directly to NTTI of care listed above. I understand I am financially responsible for all charges and services. I agree that photographs and photographic copies of this authorization shall be valid. I give permission for documentation and photographs of any pre-existing problems to be taken and used by NTTI and the Trichologist at NTTI.

Client Signature (Guardian if Minor)

Choose signature style

Signature preview

Date

Trichologist Signature

Choose signature style

Signature preview

Date

Disclaimer: The National Trichology Training Institute only provides precautionary measures and knowledge to possibly prevent the progression of hair loss. NTTI and Connie Judge assume absolutely no liabilities for any injuries resulting from information provided in this consultation to students or consumers. Individuals knowingly and willfully assume all such risks and responsibilities upon themselves and hold harmless NTTI and Connie Judge and any parties associated with NTTI with respect to all hair loss and health issues, whether arising from negligence of NTTI or otherwise.

Medical History

NTTI • Confidential

Client completesClient completes all medical, surgical and family history.

Name

Date

Preventative Medical Care

Date of last pap smear

Last menstrual cycle

Date of last mammogram

Date of last bone density

Do you have a history of:

Have you had:

Other procedures

Birth Control Method

Other birth control

Please mark any Medical Illnesses

Cancer (type and year)

Medications

Do you take any of the following?

Other medications

Injectable numbing medications

Other numbing

Reactions to hair products, creams, ointments, or lotions?

Any known drug/environmental allergies (tape/adhesive, etc.)?

Have you ever had issues with anesthesia?

Student Consultation NotesBlue for observations · Red to address · Yellow to research

Systems Review

NTTI • Confidential

Yes / No medical history

Client completesClient answers each Yes / No item.

Eyes

Wear glasses

Wear contact lenses

Experience blurring

Eyes red or inflamed

Cataracts

Glaucoma

Eyes — Other

Cardiovascular

High blood pressure

Enlarged heart (heart failure)

Heart attack

Angina (chest pains)

Irregular beats

Heart pacemaker

Heart bypass

Valve disease or prolapsed

Cardiovascular — Other

Ears, Nose & Throat

Hearing aids

Sinus trouble

Hay fever

Allergies

Allergies — When

Genitourinary

Bladder infections

Urination discomfort

Kidney stone

Kidney failure

Urine color change

Urinary — When

Infectious Diseases

Hepatitis (A, B, or C)

HIV

Hormones

Have you had your hormones tested?

Please explain results

Current or past hormone replacement therapy

Hormones — Symptoms

Hot flashes

Mood swings

Memory loss

Weight gain

Loss of libido

Abnormal pap smears

Vaginal infection

Menstrual periods abnormal

Para-menopause

Pain with menstrual periods

Presently on birth control

If pregnant, how many months?

Hormones — Other

Lungs / Respiratory / Endocrine

Asthma

Thyroid disorder

Diabetes

Cough

Tuberculosis

Emphysema

Blood clots

Shortness of breath

Internal

Gallbladder

Colitis / inflamed

Had a detox / cleansed colon

Bowel disease

Pancreatitis

Hepatitis

If detox: when?

Musculoskeletal

Arthritis

Stiff, painful joints, back, muscles, arms, or legs

Swollen joints

Gastrointestinal & Diet

Diet (appetite)

Explain

How much water intake?

Digestive

Heartburn

Ulcer disease

Frequent nausea / vomiting

Hemorrhoids

Constipation or diarrhea

Constipation / diarrhea — what type?

Skin

Sensitive to poison ivy / oak

Athlete's foot

Dry itchy hands

Dry itchy scalp

Reaction to jewelry

Neurology

Headaches

Migraines

Sleep problems

Problems with stress

Nerves

Stroke / paralysis

Seizures

Dizziness

Loss of sensation / numbness

Consider yourself nervous

Migraines — Explain

Cancer History

Any family members with history of cancer?

Malignant Melanoma

Personal history of cancer?

Malignant Melanoma

Family History

Biological family only (grandparents, mother, father, brothers, sisters, aunts, uncles). Do not consider yourself.

Dandruff — who?

Psoriasis — who?

Hair loss issues — who?

Other skin disease — who?

Baldness — who?

Diabetes — who?

High Blood Pressure — who?

Lupus — who?

Student Consultation NotesBlue for observations · Red to address · Yellow to research

Consultation Conclusion

NTTI • Confidential

Office use only

Student completesCompleted entirely by the student trichologist after the consultation.

Initial Visit?

Consultation?

Chief Complaint — describe hair and scalp condition

Duration — how long has the hair loss problem been present?

Present Medication & History

Summarize the client's medications chronologically, then record allergies, blood thinners, diabetes, pregnancy and pacemaker status.

Allergies

Blood thinner / blood pressure medication

Diabetic

Pregnant

Pacemaker

Consultation / Initial Visit Conclusion

Treatment Plan

Trichologist Signature

Choose signature style

Signature preview

Date

Review & Finalize

NTTI • Confidential

Verify all signatures then print or download

Student completesVerify every signature, then print or download the packet.

Patient QuestionnaireNo date

Not signed

HIPAA ConsentNo date

Not signed

Waiver — ClientNo date

Not signed

Waiver — TrichologistNo date

Not signed

Conclusion — TrichologistNo date

Not signed

Client completesClient must complete

Patient Questionnaire signature
HIPAA consent name & signature
Waiver signature

Student completesStudent must complete

Student name & enrollment details
Chief complaint & duration
Conclusion (clinical impression)
Treatment plan
Trichologist signature

Saves as NTTI-Consultation-form.pdf —