I. Basic Info:
1. Do you currently have any hair/scalp issue(s)? Yes No
2. If yes, please choose the closest options (multiple options are permitted): Hairloss Thinning of Hair Dandruff Damaged/Dry/Rough Hair Split-ends Oily Scalp Dry Scalp Premature Greying of Hair Scalp Psoriasis
3. How often do you wash your hair? Everyday 2-3 times per week Once a week
4. Does your shampoo contain SLS/SLES? Yes No
5. What do you think is the quality of water with which you wash your hair? Hard Soft/Normal Don’t Know
6. Do you regularly oil your hair Yes No
7. Do you feel that your hair growth is normal (a growth of 1-1.1/2 inch per month is considered normal)? Yes No
8. Do you regularly plait or braid your hair? Yes No
9. Are you a regular swimmer? Yes No
10. Do you blow dry your hair often? Yes No
11. Do you go for salon treatments Yes No Perming Straightening Colouring and/Bleaching Styling involving relaxers Heat Treatment/Curlers Any Other
12. How often do you take the salon treatments except colouring? Few times a year Once every month Once every week
13. How often do you colour your hair? Never Once a while Once every week Once every 1-2 months
14. Do you use any styling products-Serums/Gels etc? Yes No
II. Hair/Scalp Health
2. How long have you suffered with hair loss or thinning? Only recently (less than 6 months) 6 months to 2 years 2 years to 4 years Greater than 4 years
3. Estimate the number of hair that you currently lose
Nominal i.e less than 20 hair per day 20-50 hair per day 50-100 hair per day More than 100 hair per day
4. Have you experienced almost total hair loss on your head? Yes No
5. Have you experienced total hair loss on your face or any specific part of your body? Yes No
6. Is there a history of hair loss in your family? If so, which family member(s)? Father Mother Grandparents Uncle Brother
7. Describe the thinning areas of your scalp? Smooth i.e no hair at all Short “weak” hair
8. Describe the texture of your hair. Thin/Fine/Smooth, Normal, Damaged/Rough/Coarse/Dry/Brittle with or without split-ends
9. Is your scalp Flaky? Itchy? Dry? Oily? Normal? Have spots or acne? Prone to dandruff Psoriasis
10. Does your scalp weep (sore with continuous discharge)? Yes No
11. Is there a crust build up on your scalp? Yes No
12. Does your scalp sweat a lot? Yes No
13. Is your hair grey? Yes No Just Starting, Less than 10%, 10-50%, More than 50%
III. Medical
1. Is your general health and fitness Yes No
2. Are you under constant pressure or stress? Yes No
3. Are you having abnormal BP? Low High Normal
4. Have you had a blood test in the last 12 months? Yes No
5. Do you have any clinical abnormalities, either now or in the recent past that necessitated prolonged medication? Yes No
6. Please detail on the previous answer as elaborately as possible
7. Are you currently having treatment by chemotherapy and/or radiation therapy? Yes No
8. Do you take any prescription medicines? Yes No
9. Do you have an iron deficiency, or any other form of dietary deficiency? Yes No Unsure
10. Do you have an allergies? Yes No
11. What form of contraception do you use, if any?
The Pill Barrier Contraceptives (ie condoms) IUD Other
12. Have you recently given birth and are breast feeding Yes No
13. Are you, or is your partner currently pregnant? Yes No
14.Have you had a raised temperature/fever due to illness in the last 3-6 months? Yes No
Do you give blood (are you a regular blood donor)? Yes No
IV. Past Treatments
1. Please specify the treatment(s), if any that you have taken or undergone for hair or scalp problem
2. If the answer to the above question is Yes, for how long? 0-3 months 4-7 months More than 7 months
3. How did it work Thickened the hair a lot Thickened the hair a bit Stopped my hairloss Slowed my hairloss Did not work at all
V. Diet & Lifestyle
1. What type of diet do you have? Balanced with non-vegetarian Lacto Balanced Vegetarian (milk/cheese and vegetarian diet) Lots of fast food and spicy stuff Whatever comes my way at whatever time
2. Has your weight changed dramatically in the last 6 months? Weight Loss Weight Gain No Dramatic Weight Change
3. Are you obese Yes No
4. Do you exercise regularly? Yes No
5. If the answer to the above question is yes, please specify whether you are into body building? Yes No
6. Do you take any mineral or vitamin supplements? Yes No
If 'yes' please specify:
7. Do you work in an environment that exposes to you chemicals/dust/pollution/etc.on a daily basis? Yes No
8. Are you impulsive and get worked up easily? Yes No
VI. If you have any extra comments about your hairloss or scalp problem please inform us in the space provided:
VII. Personal Information
