Registered with
The Institute of Trichogists

Founded 1902

Online Diagnosis

Welcome to the online page.

If you are unable to visit us, this section gives you the option to seek some answers concerning hair fall, a hair condition or a scalp problem you may have. Please feel free to complete our carefully constructed diagnostic questionnaire. If helping your condition is important to you, it is, therefore, important to fill out the form as comprehensibly as possible so we can offer the correct diagnosis and advise.

We hope the form is user friendly and easy to follow.

Once the completed form has been received and revised by us, we will then contact you to discuss the problem and advise accordingly.

We look forward to hearing from you.

About you

Please let us know the following:-

The entries with a * by the box must be filled in. The boxes without the * are optional.

Title:	MrMrsMissMs *
First Names:	*
Surname:	*
Street and Number:
Town/City:
County:
Postcode:
Country:
Home Number:
Work Number:
Mobile Number:	*
Occupation:
Fax:
E-mail:	*
Confirm E-mail:	*
Date of Birth:
How did you hear about the Spencer Clinic?	Website Yellow pages Medical Referal Family/Friend Referal Other
Which of these covers your complaint:	Hair Loss Scalp ProblemHair Condition Problem
Please indicate your Hair Type:	EuropeanAfro CaribbeanAsian

Hair Loss

Are you suffering from a hair loss complaint?
If yes please continue with this section, if no go to Your Scalp section. NoYes

Please indicate where the area(s) of loss is occuring ie Front hair line area, top, crown, side or back?

How long ago did you first notice any signs of hair loss?

Have you seen hair falling out? NoYes

If yes, how long ago did the hair fall begin?

If no, when did you first notice a loss of hair?

Your Scalp

Which of the following best describes the condition of your scalp?

Flaky	Itchy	Dry
Oily	Normal	Spots

Is it red & weepy (moist)?
Is it dry, hard & crusty?

Indicate any other scalp symptoms:

General Health

Any physical illness, disease or deficiency before hair complaint began? NoYes

Any nervous system disorders ie. anxiety, shock, depression before hair complaint began? NoYes

Do you knowingly suffer from any of the following:-

Anaemia	Thyroid Problems	Liver Problems
Male/Female Hormone Inbalance	Diabetes	Migraine
Prostate Problems	Renal Failure	Crohn's Disease
Polycystic Ovarian Syndrome	Endometriosis	Depression
Hypertension (High blood pressure)
Hypotension (Low blood pressure)

Please provide any further helpful information:

Are you currently having treatment by chemotherapy and/or radiation therapy? NoYes

Do you take any prescription medicines? NoYes

If yes, please give details of medicine and reason for prescription?

Do you take the contreceptive pill? NoYes

Have you recently used any medication or treatment for your condition? NoYes If yes, which type and for how long?

Have you had any help or advice from any of the following? TrichologistHair DresserDermatologistG.POther

If other, who?

Hair Styling

Do you, or have you ever used, extentions (bonding) or a weave-on? NoYes

Do you wear, or have you ever worn, your hair back tightly in a pony tail or bun? NoYes

Do you have, or have you ever had, plaits, braids, cane rows etc? NoYes

Do you wear, or have you ever worn, rollers, curlers etc in bed overnight? NoYes

Hair Health

How often do you wash your hair:

Do you use chemicals on your hair? e.g Bleach, perm solutions, hair colourings, relaxers or any other. If yes, please answer both questions below:-

Yes	Which ones:
	How often:
No

When you feel you have answered all the relative questions on this form, simply click on the ‘submit diagnosis’ button below or, alternatively, call us direct on our helpline on 0207 584 4255 and ask to speak to either Richard Spencer or Samantha Stewart (afro hair specialist)