Hair and Scalp

Please allow our Trichologist- NISHA SHAH to help you resolve any of your hair & scalp concern by answering of this Questions.

What is your name?

Gender

Male

Female

Age?

Your Mobile Number (Please specify with country code)

Your Email Address

Any medical conditions?

Yes

No

Do you take any Supplements or Vitamins?

Yes

No

Are you suffering from any stress issues?

Yes

No

Did you just have a baby?

No

3-6 months

6-9 months

9-12 months

12+

Do you have any nutritional deficiencies?

Yes

No

Are you taking contraceptives (birth-control pills) Or Did u recently stopped taking them?

Yes

No

How many times do you wash your hair?

Once a week

2-3 times a week

4-5 times a week

Everyday

Scalp texture

Dry

Oily

Normal

In which areas are you experiencing hair loss?

Top of head only In which areas are you experiencing hair loss?

Top and Sides of head (all over the scalp) In which areas are you experiencing hair loss?

At the front (receding/ frontal hairline) In which areas are you experiencing hair loss?

At the back/vertex area In which areas are you experiencing hair loss?

Small patches in random areas

Do u use any heat styling tools?

Yes

No

Do you have Dandruff?

Yes

No

Hair Type

Wavy

Straight

Curly

Chemical Treated

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Hair and Scalp

Hair and Scalp

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