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Solutions      Approach       Instant advice

Instant advice

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If you want to get an instant advice regarding your specific ongoing hair problem, you can fill out this questionnaire form, used in Trichology for an initial evaluation. To submitt an inquiry, you have to fill out only required fields, however, the more detailed information you will provide, the better advice you might be gettig1 Also, as your possible diagnosis might be approximately defined only from fragments of information, you give, any additional details you may believe are important to complete your problem overall description, should be provided in section "your comments", especially in more serious condition case! For example, in addition to listed questions, in case of progressing and/or heavy hair loss quite important information will be more detailed information on it’s pattern: is it limited focal patchy type; is it more of a diffuse pattern; is a hair loss all over; is hair loss limited to the top of the scalp, temples, occipital area; is it asymmetrical or symmetrical in appearance; does hair loss involve inflammation; is there any scar tissue; is there any crusting or scaling of the skin; are there any lumps and bumps in the skin; etc. Similar extent of applicable details provided is important in regards to any other specific hair and/or scalp problem. Also since quite often the great concern and even panic sometimes arise with worsening of ongoing hair loss, you can learn how to determine on your own the least about the nature and extent of ongoing rapid hair shedding with the help of specific hair loss tests, used by Trichologists.

1. General info: How did you learn about us?

If other please specify:

2. Your first name, last name, residence place:

3. Your e-mail address, telephone number:

4. Your age, sex, race, height, weight, occupation or business:

5. How long and what kind of hair problems you have ?

6. Do you have a hair loss and what kind ?

If other please specify:

7. How would you describe your general health ?

Have you ever had any of the following:

Within past 5 years:

None  
Surgeries  
Narcosis  
Allergies  
Antibiotics  
Hormones  
Depression  
Other  

Any prescription medications you take on regular basis?

Are you experiencing or have you experienced any stress?

If other for any of above, please specify:

8. Is there any family history of hair loss and/or other related problems?

9. Your hair and scalp condition: hair loss area?

Condition of your scalp:

Normal  
Oily  
Dry  
Dandruff  
Itchy  
Sensitive  
Allergic  
Other  

Your hair type:

Normal  
Oily  
Dry  
Combined  
Damaged  
Straight  
Wavy  
Curly  
Long  
Fine  
Brittle  
Split ends  
Other  

Your hair length and natural colour?

If other for any of above, please specify:

10. Your hair care: how often do you wash hair?

Choice of Shampoo (supermarket shelf, salon, natural, special, pharmaceutical, etc.):

Conditioner / Mask / Cream (regular, light, natural, treatment, special, etc.):

Hair styling (spray, gel, mousse, foam, etc.)?

How often do you have your hair cut?

11. Hair processing: hair dyeing (if yes for how long and how often)?

Hair bleaching (if yes for how long and how often)?

Hair perming (if yes for how long and how often)?

12. If any other hair works, including additions, extensions, replacement, masking, etc., please specify:

13. Hair treatments (if any what kind and for how long)?

14. Special diets / dietary regulations:

Food supplements / vitamins:

15. Smoking (if yes for how long and how much a day)?

16. Your comments:

17. Your questions:

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