✧ HAIR LOSS CONSULTATION ✧
primary assessment · in-depth analysis
complete the form with care – your hair journey starts here
1. Personal information
Full name
Age
Gender
Male
Female
Other
Mobile number
Occupation
2. Main complaint
How long are you experiencing hair fall?
Less than 3 months
3–6 months
More than 6 months
Type of hair fall:
Gradual thinning
Sudden hair fall
Patches
Breakage
Approximate hair fall per day:
Less than 50
50–100
More than 100
Has it increased recently?
Yes
No
Same
3. Other symptoms
Scalp itching
Dandruff
Redness
Oily scalp
Dry scalp
Split ends
Graying Of Hair
4. Medical history
Any illness/Surgery in last 3–6 months (Typhoid, Fever, Covid etc.)?
Yes
No
Details (if yes):
Hormonal issues / PCOS (for females)?
Yes
No
Anemia / Vitamin D / B12 deficiency?
Yes
No
Pregnancy / Lactation:
Planning
Currently Pregnant
Breastfeeding
None
5. Lifestyle
Diet:
Veg
Non-Veg
Low Protein
Sleep:
Good (7–8 hrs)
Poor
Water intake:
Low
Medium
Good
Smoking / Alcohol?
Yes
No
6. Family history
Family history of hair loss?
Yes
No
7. Expectations
Control hair fall
New hair growth
Increase thickness
Improve volume
✦ SUBMIT CONSULTATION ✦