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Your name Email Age
Sex MaleFemale
Are you currently experiencing an increase in your hair loss? YesNo
At what age did you start losing your hair?
Describe the pattern(s) of your hair CrownFrontGeneral Thinning
Do you have a family history of hair loss? MotherFatherBrotherUncleNone
Estimate the numbers of hairs you are losing per day YesNo
Where do you notice the most hair loss? YesNo
About what percentage of your hair have you lost? YesNo
Describe the thinning areas of the scalp YesNo
Have you tried any topical solutions for your hair loss? YesNo
Others (specify)
What do you believe to be the major contributing factor(s) causing your hair loss? MotherFatherBrotherUncleNone
Describe the texture of your hair Please check all that apply NormalOilyDryThin/FineDandruffDamagedBrittleSplit Ends
Do you: Please check all that apply SwimBlow dry your hairPerm/Colour treat it
If your hair is grey, how much? Just startingLess than 10%10% to 40%40% to 70%Over 70%
Describe your scalp Please check all that apply TightLooseSeborrheaItchyPsoriasisDryOily
What hair care product(s) are you currently using?
Description of your general health. Have you had any illnesses that you think might be affecting your hair?
Are you taking any medication that might be affecting your hair?
Are you a vegetarian? YesNo
Do you exercise regularly? YesNo
Describe your ability to cope with stress: PoorAverageGood
Are you on a weight loss diet? YesNo
Have you lost a lot of weight recently? YesNo
Any questions or comments?
