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

internet search internet add press friend relative other source

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 ?

No Slight Moderate Heavy Going bald Other N/A

If other please specify:

7. How would you describe your general health ?

Perfect Good Reasonable Poor Other

Have you ever had any of the following:

None High blood pressure Blood clots/Vein thrombhosis High cholesterol Heart problems Pneumonia Asthma Diabetes Kidney problems Liver problems Thyroid problems Acid reflux/heartburn Arthritis Radiation Therapy Other N/A

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?

Top Front Isolated spots Overall thinning Completely bald Other N/A

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?

Twice a day and more Daily Almost every day Every other day Twice a week Once a week Every other week and less

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?

Everyday Once a week Once a month Every other month and less Tips only None N/A

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: