FK Hairs Wellness Intake Form

Section 1 of 11

Basic Information

Full name *

Email address *

Age *

City & Country *

Occupation (optional — helps me understand your lifestyle and stress patterns)

Section 2 of 11

Main Hair Concerns

What are your primary hair concerns? * (select all that apply)

Hair thinning Excess shedding Breakage Slow growth Scalp irritation Dandruff / flaking Oily scalp Dry scalp Hormonal hair concerns Postpartum shedding Female pattern hair loss Overall hair wellness Other

Please describe your concern:

How severe would you say your concern is?

Mild — I notice it but others may not Moderate — noticeable to me and others Severe — significant loss or thinning visible Very severe — affecting my confidence and daily life

What are you hoping to gain from this consultation? *

Section 3 of 11

Hair History

When did you first notice changes in your hair? *

Less than 3 months ago 3–6 months ago 6–12 months ago 1–2 years ago More than 2 years ago

Was the change sudden or gradual?

Sudden — happened quickly over a short period Gradual — slowly over time I'm not sure

Is the thinning or shedding concentrated in a specific area?

Crown / top of head Front hairline Temples Part line Diffuse / all over Sides Nape / back

Has the shedding or thinning worsened recently?

Yes — noticeably worse Staying about the same Slightly improving Fluctuates

Has anyone in your family experienced hair thinning or hair loss?

Yes — on my mother's side Yes — on my father's side Yes — both sides No I'm not sure

Have you been diagnosed with any hair or scalp condition by a doctor?

Yes No I haven't seen a doctor about it

Please specify the diagnosis:

Section 4 of 11

Wellness History

This information helps me understand the internal factors contributing to your hair concerns. Everything shared here is strictly confidential.

Have you experienced major stress in the past 12 months? *

Yes — work or career stress Yes — relationship or family stress Yes — bereavement or loss Yes — financial stress Yes — health-related stress Yes — other No significant stress Prefer not to say

Stress is one of the most overlooked triggers of hair loss. A simple yes is enough — no details required unless you wish to share.

Have you experienced any of the following in the past 12 months? (select all that apply)

Major illness or surgery Rapid weight loss or crash diet Pregnancy or postpartum Menopause or perimenopause Significant hormonal changes None of the above

Do you have any of the following? (select all that apply)

Thyroid condition PCOS Anaemia or iron deficiency Hormonal imbalance Autoimmune condition Diabetes or insulin resistance Gut or digestive issues Anxiety or chronic stress None of the above Prefer not to say Other

Please specify your condition:

Are you currently taking any medications? (select all that apply)

Birth control / hormonal contraceptives Antidepressants Blood pressure medication Thyroid medication Acne medication / Accutane Long-term antibiotics No medications Prefer not to say Other

Please specify:

Are you currently taking any supplements?

Yes No

Please list your supplements and dosages:

Section 5 of 11

Nutrition

Hair is built from what you eat. These questions help me identify any nutritional gaps that may be contributing to your hair concerns.

How would you describe your diet?

Omnivore — I eat everything Pescatarian — fish but no meat Vegetarian Vegan Other

Please describe:

Do you have any food allergies or intolerances? (select all that apply) *

Gluten Dairy / lactose Nuts Shellfish Eggs Soy None Other

Please specify:

Do you regularly eat enough protein?

Yes — I prioritise protein at every meal Somewhat — I eat some protein daily No — I rarely think about protein I'm not sure

Do you skip meals frequently?

Yes, often Sometimes Rarely Never

How much water do you drink daily?

Less than 1 litre 1–1.5 litres 1.5–2 litres 2+ litres

Are you currently on or have you recently been on a restrictive diet?

Yes — currently Yes — recently (last 6 months) No

What type of diet?

Do you experience any digestive issues? (select all that apply)

Bloating Constipation Acid reflux IBS symptoms Food reactions None

Section 6 of 11

Hair Practices

Do you colour or bleach your hair? (select all that apply)

Yes — full colour at salon Yes — highlights or balayage Yes — I bleach my hair Yes — box dye at home No — natural / uncoloured

How often?

Do you use any chemical treatments?

Keratin / Brazilian blowout Relaxer / chemical straightening Perm None

How often do you use heat styling tools?

Daily A few times a week Occasionally Never

Do you wear extensions?

Yes — regularly Occasionally No

What type of extensions?

Do you regularly wear tight hairstyles?

Tight ponytails Tight buns Slick-back styles Tight braids No — I wear it loose mostly

How often do you wash your hair?

Daily Every 2–3 days Once a week Less than once a week

Do you dry your hair completely after washing?

Yes — always blow dry on low heat Yes — blow dry on high heat Sometimes — I air dry occasionally No — I mostly air dry No — I often sleep with wet hair

Please list every product and oil you currently use on your hair and scalp: *

Section 7 of 11

Upload Your Files

Please upload your bloodwork results and scalp photos before your consultation. The more I can see, the more precise and personalised your session will be. Good lighting is essential for photos — natural daylight works best. No filters.

Bloodwork results (if available)

📋

Upload your bloodwork results

Results must be no older than 6 months

PDF, JPG, PNG accepted

Please upload bloodwork no older than 6 months. Most helpful markers: Ferritin, Iron, Vitamin D, B12, Zinc, TSH, Free T3, Free T4, DHT, Testosterone, DHEA-S, Estrogen, Progesterone, CBC, Glucose, Cholesterol

Scalp & hair photos *

📸

Upload 3–5 scalp photos

JPG, PNG, HEIC accepted

📷 Crown photoPart hair down the middle, photograph directly from above in good light

📷 Hairline photoPull all hair back, photograph your front hairline straight on

📷 Temple photosOne photo of each temple area where hairline meets the side

📷 Full lengthHair down showing overall density, length, and thickness

📷 Concern area (optional)Any other specific area you want me to look at closely

Section 9 of 11

Detailed Nutrition

This is what makes the Full Program truly personalised. Your meal plan will be built around the food you actually eat — your culture, your kitchen, your preferences. Please be as detailed as possible.

Walk me through a typical day of eating — what do you usually eat from morning to night? *

What time do you usually eat your first meal of the day?

Before 8am 8am – 10am 10am – 12pm After 12pm — I skip breakfast entirely

Do you experience cravings? What kind?

Sugar / sweets Salty foods Carbs / bread / pasta Caffeine / coffee Fatty or fried foods No significant cravings

How often do you eat processed or packaged foods?

Daily — most of my meals are processed or packaged A few times a week Occasionally Rarely — I mostly cook from scratch

Do you consume enough healthy fats daily? (olive oil, avocado, nuts, fatty fish, seeds)

Yes — I eat healthy fats regularly Sometimes — not consistently Rarely — I tend to eat low fat I'm not sure

Section 10 of 11

Your Food Culture & Gut Health

This is what makes FK Hairs different. Your meal plan will be built around the food you grew up with, the ingredients already in your kitchen, and the cuisine that feels like home — not a generic plan from the internet.

What cuisine do you primarily eat at home? *

What foods did you grow up eating regularly?

What are your comfort meals — the dishes you always come back to?

Are there foods that are important to your culture or religion that you eat regularly or avoid?

This helps me respect your dietary boundaries when building your meal plan.

What ingredients are always in your kitchen? *

This is gold for personalisation — I can build your entire plan around what you already have.

Are there any foods you strongly dislike or refuse to eat?

Do you mostly cook at home or eat out?

Mostly cook at home Mix of both Mostly eat out or order in

Gut Health

A compromised gut directly suppresses nutrient absorption and fuels scalp inflammation. These questions help me understand what's happening internally.

Do you experience any of the following gut symptoms? (select all that apply)

Bloating after meals Constipation Acid reflux or heartburn IBS symptoms Irregular digestion Food reactions or sensitivities None of the above

Stress & Nervous System

Describe your current stress levels in your own words:

B10

Do you experience any of the following? (select all that apply)

Chronic overwhelm Burnout symptoms Difficulty relaxing or winding down Racing thoughts at night Anxiety or panic Emotional exhaustion None of the above

Hormones

B11

Do you experience any of the following hormonal symptoms? (select all that apply)

Irregular menstrual cycles Severe PMS Hormonal acne Unwanted facial or body hair Rapid hormonal shifts Low libido Weight gain around abdomen None of the above

Lifestyle

B12

How would you describe your activity level?

Sedentary — mostly sitting throughout the day Lightly active — occasional walks Moderately active — exercise 2–3x per week Very active — exercise 4+ times per week

B13

Do you smoke?

Yes No Occasionally

B14

How often do you consume alcohol?

Never Rarely Occasionally — 1–2x per week Regularly — 3+ times per week

B15

Describe your typical sleep schedule:

Consistent — same bedtime and wake time daily Somewhat consistent — varies by 1–2 hours Irregular — varies significantly day to day Night shift or irregular work hours

B16

Are you exposed to any of the following? (select all that apply)

High sun / UV exposure Hard water / limescale Swimming pool / chlorine Pollution or environmental stress Sedentary desk job None of the above

Section 11 of 11

Commitment & Consent

How did you find FK Hairs?

TikTok Instagram Word of mouth / referral Google search Other

Please specify:

Is there anything else you would like me to know before your consultation?

Is there anything else you feel is relevant to your consultation that you haven't had the chance to share? (health, emotional, lifestyle, or anything at all)

Are you willing to commit to long-term consistency and lifestyle changes to support your hair transformation? *

Yes — I am fully committed and ready to do the work Yes — I will do my best, understanding it takes time Mostly — some changes will be easier than others I'm not sure yet — I want to hear the plan first

Hair transformation is a long-term ritual. Real results take consistency, patience, and a willingness to make small but meaningful changes to your daily habits. There is no wrong answer here — honesty helps me calibrate the right approach for you.

Please read before submitting

The FK Hairs Ritual is a wellness and educational service. Farah is not a doctor, dermatologist, or licensed medical practitioner. All recommendations are based on years of professional hairdressing experience, trichology study, and holistic wellness practices. This consultation is not intended to diagnose, treat, cure, or replace medical advice. If you are experiencing significant, sudden, or progressive hair loss, I always encourage you to also consult a qualified physician or dermatologist.

I confirm I have read and understand the disclaimer above. I understand this is a wellness and educational service, not a substitute for medical care. *

I confirm all information I have provided is accurate and complete to the best of my knowledge. *

I consent to FK Hairs storing my intake information securely for the purpose of my consultation only. *

The FK Hairs
Full Program

Basic Information

Main Hair Concerns

Hair History

Wellness History

Nutrition

Hair Practices

Upload Your Files

Detailed Nutrition

Your Food Culture & Gut Health

Commitment & Consent

Please read before submitting

Thank you,
your form is submitted

The FK HairsFull Program

Basic Information

Main Hair Concerns

Hair History

Wellness History

Nutrition

Hair Practices

Upload Your Files

Detailed Nutrition

Your Food Culture & Gut Health

Commitment & Consent

Please read before submitting

Thank you,your form is submitted

The FK Hairs
Full Program

Thank you,
your form is submitted