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Name

Phone

How old are you?

Gender

Male

Female

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Which image best describes your hair loss?

Stage-1

Stage-2

Stage-3

Stage-4

Stage-5

Stage-6

Stage-7

Stage-8

Do you have a family history of hair loss?

Father or anyone from father's side of the family

Father or anyone from father's side of the family

Both

None

Do you have dandruff?

No

Mild dandruff (small white flakes)

Heavy dandruff (sticky dandruff found in nails on scratching or visible on clothes)

Diagnosed with Psoriasis / Seborrheic Dermatitis

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Do you feel constipated?

No / Once in a while

Yes (fewer than 3 stools a week)

Unable to pass stool properly / feeling unsatisfied after passing stools

Suffering from Irritable Bowel Syndrome

Do you have Gas, Acidity or Bloating?

No

Sometimes (1-2 times a week or when I eat out)

Often (3+ times a week)

How are your energy levels during the day?

Always high / Normal energy levels throughout the day

Low when I wake up, then gradually increase

Very low in the afternoon

Low by evening/night

Always low

Are you currently taking any supplements or vitamins for hair?

Yes

No

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Upload your scalp picture for our hair experts to check.

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