Further details

1. Is the problem you are experiencing:
Hair Loss? Scalp Problem? Both

2. How long have you been suffering from hair loss or thinning?*

3. Approximately how much hair have you lost
Under 25% 25-50% 50-75% Over 75% 100%

4. Is there a history of hair loss in your family?
Yes No

5. Is your hair type:
Afro-Caribbean Asian European

6. Is your scalp:
Flaky? Itchy? Dry? Oily? Normal? Affected by spots or acne?

7. Does your scalp weep or is there a crust build up?
Yes No

8. Please describe any other symptoms relating to question 7

9. Are you currently having treatment by chemotherapy and/or radiation therapy?
Yes No

10. Do you take any prescription medicines?
Yes No

11. Do you have any allergies?
Yes No

12. Have you used any medication or treatment for hair loss or scalp conditions in the past?
Yes No

13. If yes, which treatment and for how long?

14. Have you received treatment or advice from:
Trichologist Hair dresser Dermatologist G.P. None

15. If yes to any of the above, what advice and treatment?

16. Do you have a well balanced diet?
Yes No

17. Do you take any minerals or vitamins?
Yes No

18. If you do take minerals or vitamins please specify:

19. Do you actively participate in sports

20. Do you or have you used or had any of the following:

22. Do you use chemicals your hair?
Yes No

23. If you do use chemicals on your hair please specify: