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1. Do you currently have any hair/scalp issue(s)? YesNo
2. If yes, please choose the closest options (multiple options are permitted): HairlossThinning of HairDandruffDamaged/Dry/Rough HairSplit-endsOily ScalpDry ScalpPremature Greying of HairScalp Psoriasis
3. How often do you wash your hair? Everyday2-3 times per weekOnce a week
4. Does your shampoo contain SLS/SLES? YesNo
5. What do you think is the quality of water with which you wash your hair? HardSoft/NormalDon’t Know
6. Do you regularly oil your hair YesNo
7. Do you feel that your hair growth is normal (a growth of 1-1.1/2 inch per month is considered normal)? YesNo
8. Do you regularly plait or braid your hair? YesNo
9. Are you a regular swimmer? YesNo
10. Do you blow dry your hair often? YesNo
11. Do you go for salon treatments YesNo If yes, please specify: PermingStraighteningColouring and/BleachingStyling involving relaxersHeat Treatment/CurlersAny Other
12. How often do you take the salon treatments except colouring? Few times a yearOnce every monthOnce every week
13. How often do you colour your hair? NeverOnce a whileOnce every weekOnce every 1-2 months
14. Do you use any styling products-Serums/Gels etc? YesNo
1. Norwood Hamilton
Ludwig Scale
2. How long have you suffered with hair loss or thinning? Only recently (less than 6 months)6 months to 2 years2 years to 4 yearsGreater than 4 years
3. Estimate the number of hair that you currently lose
Nominal i.e less than 20 hair per day20-50 hair per day50-100 hair per dayMore than 100 hair per day
4. Have you experienced almost total hair loss on your head? YesNo
5. Have you experienced total hair loss on your face or any specific part of your body? YesNo
6. Is there a history of hair loss in your family? If so, which family member(s)? FatherMotherGrandparentsUncleBrother
7. Describe the thinning areas of your scalp? Smooth i.e no hair at allShort “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 dandruffPsoriasis
10. Does your scalp weep (sore with continuous discharge)? YesNo
11. Is there a crust build up on your scalp? YesNo
12. Does your scalp sweat a lot? YesNo
13. Is your hair grey? YesNo If Yes, how much? Options Just Starting,Less than 10%,10-50%,More than 50%
1. Is your general health and fitness YesNo
2. Are you under constant pressure or stress? YesNo
3. Are you having abnormal BP? LowHighNormal
4. Have you had a blood test in the last 12 months? YesNo
5. Do you have any clinical abnormalities, either now or in the recent past that necessitated prolonged medication? YesNo
6. Please detail on the previous answer as elaborately as possible
7. Are you currently having treatment by chemotherapy and/or radiation therapy? YesNo
8. Do you take any prescription medicines? YesNo
9. Do you have an iron deficiency, or any other form of dietary deficiency? YesNoUnsure
10. Do you have an allergies? YesNo If Yes, Please specify
11. What form of contraception do you use, if any?
The PillBarrier Contraceptives (ie condoms)IUDOther
12. Have you recently given birth and are breast feeding YesNo
13. Are you, or is your partner currently pregnant? YesNo
14.Have you had a raised temperature/fever due to illness in the last 3-6 months? YesNo
Do you give blood (are you a regular blood donor)? YesNo
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 months4-7 monthsMore than 7 months
3. How did it work How did it work?Thickened the hair a lotThickened the hair a bitStopped my hairlossSlowed my hairlossDid not work at all
1. What type of diet do you have? Balanced with non-vegetarianLacto Balanced Vegetarian (milk/cheese and vegetarian diet)Lots of fast food and spicy stuffWhatever comes my way at whatever time
2. Has your weight changed dramatically in the last 6 months? Weight LossWeight GainNo Dramatic Weight Change
3. Are you obese YesNo
4. Do you exercise regularly? YesNo
5. If the answer to the above question is yes, please specify whether you are into body building? YesNo
6. Do you take any mineral or vitamin supplements? YesNo
If 'yes' please specify:
7. Do you work in an environment that exposes to you chemicals/dust/pollution/etc.on a daily basis? YesNo
8. Are you impulsive and get worked up easily? YesNo
VI. If you have any extra comments about your hairloss or scalp problem please inform us in the space provided:
1. TitleMrMrsMiss
2. First Name
3. Surname
4. Address
5. Town / City
6. Country
7. Postal code / Zip
8. Mobile No
9. Alternate Contact No
10. E-mail
11. Confirm E-mail
12. Company Name / Employer
13. Occupation
14. Sex FemaleMale
15. Date of Birth
16. How did you hear about HerbalGlow Segals Solutions GoogleFacebookInstagramLinkedIn
If others
