HAIR TEST QUESTIONNAIRE

HAIR ANALYSIS – APPLICATION 

 

 Personal Details (Strictly Confidential) 

 

Name:                                                     M/F (please circle) Tel:  

Address: 

Postcode:                                                        Mobile: 

Email:                                                         Age:                 Height: 

Occupation: 

First Test             Retest           (please tick) 

 How did you find us? 

 Medication (prescription only) 

 

   

 

Supplements 

 

 

 

Medical Conditions 

 

  

 

 

 

                                                                                                         Do you smoke? 

 Symptoms 

 

Please list the top five symptoms which you are currently suffering from, in order of seriousness. You can write a full medical history on the reverse of this form if you wish. 

 1 

 2 

 3 

 4 

 5 

 

Hair 

 

Place a minimum of three hairs - anywhere on the body will do - in the space below making sure that the root of the hair is attached. PLEASE DO NOT TAPE OVER THE ROOT. 

 

 

 

 

 

Medical History – please enclose extra pages if this space is not enough 

 


 

 

 

CREDIT CARD PAYMENT DETAILS

 

 VISA                                             SWITCH                                      OTHER 

 

 CARD NO:                  /                     /                     /             

 

 START DATE:            /        EXPIRY DATE:           /         SECURITY CODE:                

 (Last 3 digits on white strip on back of card above signature)

ISSUE NO:  


The Reve Pavilion 2a Guildford Park Road Guildford GU2 7ER 

01483 522133