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Complete online diagnosis
Home
About Us
Products
Blog
Contact
Complete online diagnosis
Home
About
Products
Contact
Blog
About
Intro to Hair Loss
About The Clinic
What is Trichology
Heritage
Types of hair loss
Other Hair Loss
Genetic Male pattern Hair Loss
Female Pattern Hair Loss
Hair Myths
Textured Hair
Textured Hair Loss
Textured Hair Myths
Scalp Problems
Scalp Problems
Complete online diagnosis
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Online Diagnosis
1
About You
2
Your General Health
3
Hair Loss
4
Scalp Problems
5
Your Hair Regime
About You
Title
Mr
Mrs
Miss
Ms
Rather not say
Your Name
*
First
Last
Contact Number
*
Email
*
Date of Birth
Day
Month
Year
Which of these covers your hair problems?
Hair Loss
Scalp Problem
Hair Condition Problem
Please indicate your hair type
European
African Caribbean
Asian
Your General Health
Any physical illness, disease or deficiency before hair complaint began?
Yes
No
Any nervous system disorders?
Yes
No
E.g. Anxiety, shock, depression before hair complaint began?
Do you knowingly suffer from any of the following:-
Anaemia
Thyroid Problems
Liver Problems
Male/Female Hormone Imbalance
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 receiving any medical treatment?
Yes
No
Please give details of medicine and reason for prescription:-
Do you take the contreceptive pill?
Yes
No
Have you recently used any medication or treatment for your condition?
Yes
No
Please state which type and for how long?
Have you had any help or advice from any of the following?
Trichologist
Hair Dresser
Dermatologist
G.P.
Other
Please note who else you've received advice from:-
Hair Loss
Please indicate where the area(s) of loss is occuring
E.g. 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?
Yes
No
How long ago did the hair fall begin?
When did you first notice a loss of hair?
Scalp Problems
Which of the following best describes the condition of your scalp?
Flaky
Itchy
Dry
Oily
Normal
Spots
Is your scalp red & weepy?
Yes
No
I.e. is your scalp moist
Is your scalp dry, hard & crusty?
Yes
No
How Long Have You Suffered With A Scalp Complaint?
Indicate any other scalp symptoms:
Your Hair Regime
Do you use extensions or a weave-on?
Yes
No
Do you wear your hair tightly back in a ponytail or bun?
Yes
No
Do you plait or braid your hair?
Yes
No
Do you wear rollers in bed?
Yes
No
How often do you wash your hair?
Do you use chemicals on your hair?
Yes
No
E.g Bleach, Perm Solutions, Hair Colourings, Relaxers or any other.
Please list the products or chemicals you use, and how often you use them
*
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