Hair Assement

Free Professional Diagnostic Evaluation

(Part I and VII are mandatory but it is strongly suggested that you provide the maximum possible information for the best possible evaluation and suggestions)

Please fill in the basic details our expert will contact you based on the assessment

1). Do you currently have any hair/scalp issue(s)?

Yes No

2).If yes, please choose the closest options (multiple options are permitted):

Hairloss

Thinning of Hair

Dandruff

Damaged / Dry / Rough Hair

Split-ends

Oily Scalp

Dry Scalp

Premature Greying of Hair

Scalp Psoriasis

3). How often do you wash your hair?

Everyday 2-3 times per week Once a week

4). Does your shampoo contain SLS/SLES?

Yes No

5). What do you think is the quality of water with which you wash your hair?

Hard Soft/Normal Don’t Know

6). Do you regularly oil your hair?

Yes No

7). Do you feel that your hair growth is normal (a growth of 1-1.1/2 inch per month is considered normal)?

Yes No

8). Do you regularly plait or braid your hair?

Yes No

9). Are you a regular swimmer?

Yes No

10). Do you blow dry your hair often?

Yes No

11). Do you go for salon treatments?

Yes No

If yes, please specify:

Perming

Straightening

Colouring and / Bleaching

Styling involving relaxers

Heat Treatment / Curlers

Any Other

Norwood Hamilton / Ludwig Scale image-links with options

How long have you suffered with hair loss or thinning?

Estimate the number of hair that you currently lose

Have you experienced almost total hair loss on your head?

Yes No

Have you experienced total hair loss on your face or any specific part of your body?

Yes No

Is there a history of hair loss in your family? If so, which family member(s)?

Father Mother Grandparents Uncle Brother

Describe the thinning areas of your scalp?

Smooth i.e no hair at all Short “weak” hair

Describe the texture of your hair

Is your scalp

Flaky Itchy Dry Oily Normal Have Spots Or Acne Prone To Dandruff Psoriasis

Does your scalp weep (sore with continuous discharge)?

Yes No

Is there a crust build up on your scalp?

Yes No

Does your scalp sweat a lot?

Yes No

Is your hair grey?

Yes No

If Yes, how much?

Is your general health and fitness

Are you under constant pressure or stress?

Yes No

Have you had a blood test in the last 12 months?

Yes No

Do you have any clinical abnormalities, either now or in the recent past that necessitated prolonged medication?

Yes No

Please detail on the previous answer as elaborately as possible

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

Yes No

Do you take any prescription medicines?

Yes No

Do you have an iron deficiency, or any other form of dietary deficiency?

Yes No Unsure

Do you have an allergies?

Yes No

If Yes, Please specify

What form of contraception do you use, if any?

The Pill Barrier Contraceptives (ie condoms) IUD Other

Have you recently given birth and are breast feeding?

Yes No

Are you, or is your partner currently pregnant?

Yes No

Have you had a raised temperature/fever due to illness in the last 3-6 months?

Yes No

Do you give blood (are you a regular blood donor)?

Yes No

Please specify the treatment(s), if any that you have taken or undergone for hair or scalp problem

If the answer to the above question is Yes, for how long?

0 - 3 months 4 - 7 months More than 7 months

How did it work?

Thickened the hair a lot Thickened the hair a bit Stopped my hairloss Slowed my hairloss Did not work at all

What type of diet do you have?

Balanced with non-vegetarian Lacto Balanced Vegetarian (milk/cheese and vegetarian diet) Lots of fast food and spicy stuff Whatever comes my way at whatever time

Has your weight changed dramatically in the last 6 months?

Weight Loss Weight Gain No Dramatic Weight Change

Are you obese?

Yes No

Do you exercise regularly?

Yes No

If the answer to the above question is yes, please specify whether you are into body building?

Yes No

Do you take any mineral or vitamin supplements?

Yes No

If 'yes' please specify

Do you work in an environment that exposes to you chemicals/dust/pollution/etc.on a daily basis?

Yes No

Are you impulsive and get worked up easily?

Yes No

If you have any extra comments about your hairloss or scalp problem please inform us in the space provided

Enter Your Title

First Name

Sur Name

Address

Town / City

Country

Postal Code / Zip Code

Enter Your Phone / Mobile No

Alternate Contact No

Enter Your Email

Confirm Email

Sex

Date Of Birth

How did you hear about Herbal Glow Segals Solutions?

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