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Home
History
Hair Loss
Introductory Letter from the Pharmacist
Free Diagnostic Hair Evaluation
10 Tips for Thicker Hair
Rooibos Clinical Study
Hair for Life Book
Testimonials
Hair Care
Thin-Looking Hair
Dandruff Flakes & Dry Scalp
ProScalp & Itchy Scalp
Once-A-Week Scalp Serum
Build Up Remover
Grey, White & Blonde Hair
Dry, Damaged Hair
Sensitive Scalp
African Hair Repair
Fruit Solutions
Value Size Shampoos & Conditioners
Skin Care
Advanced Anti-Aging
Scars & Stretch Marks
Ingredients
FAQs
Contact Us
Shop
My Account
0
close
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Free Diagnostic Hair Evaluation
Personal Information
Name
Email
Age
Sex
Male
Female
Description of your hair loss
Are you currently experiencing an increase in your hair loss?
Yes
No
At what age did you start losing your hair?
Describe the pattern(s) of your hair
Crown
Front
General Thinning
Do you have a family history of hair loss?
Mother
Father
Brother
Uncle
None
Estimate the numbers of hairs you are losing per day
Less than 40
40-70
Over 70
Where do you notice the most hair loss?
On your comb/brush
On your pillow
In the shower
About what percentage of your hair have you lost?
less than 10%
10% to 40%
40% to 70%
over 70%
Describe the thinning areas of the scalp
"Smooth," no hair at all
Short "weak" hair
Have you tried any topical solutions for your hair loss?
Rogaine
Propecia
Others (specify)
What do you believe to be the major contributing factor(s) causing your hair loss?
Hereditary
Stress
Poor Diet
Lack of exercise
Illness
Medication
Poor hair hygiene
Description of your hair and scalp
Describe the texture of your hair
Please check all that apply
Normal
Oily
Dry
Thin/Fine
Dandruff
Damaged
Brittle
Split Ends
Do you:
Please check all that apply
Swim
Blow dry your hair
Perm/Colour treat it
If your hair is grey, how much?
Just starting
Less than 10%
10% to 40%
40% to 70%
Over 70%
Describe your scalp
Please check all that apply
Tight
Loose
Seborrhea
Itchy
Psoriasis
Dry
Oily
What hair care product(s) are you currently using?
Description of your general health. Have you had any illnesses that you think might be affecting your hair?
Are you taking any medication that might be affecting your hair?
Are you taking any supplements and which ones?
Are you a vegetarian?
Yes
No
Do you exercise regularly?
Yes
No
Describe your ability to cope with stress:
Poor
Average
Good
Are you currently experiencing a lot of stress?
Yes
No
Are you on a weight loss diet?
Yes
No
Have you lost a lot of weight recently?
Yes
No
Any questions or comments?
Verification
Please enter any two digits
*
Example: 12
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