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Title*

Name*

Contact Number*

Email*

Age-group*

Which of these covers your hair problems?*

Which of the following best describes your hair concern?*

How long have you had your hair problems?*

Please indicate your hair type

Any physical illness, disease or deficiency before hair complaint began?

Any nervous system disorders?*

E.g. Anxiety, shock, depression before hair complaint began?

Did you give birth recently?*

Do you knowingly suffer from any of the following:*

Are you currently or recently having treatment by chemotherapy and/or radiation therapy?*

Do you have any family history of hair loss?*

Are you using contraceptive pills or used recently?*

How would you describe your daily Diet ?*

Have you recently used any medication or treatment for your hair condition?*

If yes, Please write down what did you have?

Have you had any help or advice from any of the following?*

Do you use extensions or a weave-on?

Do you plait or braid your hair?

Do you wear your hair tightly back in a ponytail or bun?

Do you wear rollers in bed?

How often do you wash your hair?

Do you use chemicals on your hair?

E.g Bleach, Perm Solutions, Hair Colourings, Relaxers or any other.

Please add anything you would like our specialists to know which is not covered above.

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