Hair Assessment -
Free Diagnostic Evaluation

 
" Simply complete the on-line questionnaire and submit. Within a few days you will receive a personal & free diagnostic evaluation. Everything will be treated with complete privacy. I look forward to hearing from you."


Pharmacist D.R. Segal.
Pharmacist and Author of "Preventing & Reversing Hair Loss"


Personal Information
Name:
Address:
City:
Country:

email address:

Age:
Sex: Male Female
Telephone:
Fax:

Description of your hair loss
Are you currently experiencing an increase in your hair loss?
no yes
At what age did you start losing your hair?
age:

Describe the pattern(s) of your hair loss:

crown front general thinning

Do you have a family history of hair loss?

none mother father brother uncle

Estimate the numbers of hairs you are losing per day :

less than 40 40-70 over 70

Where do you notice the most hair loss?

on your comb/brush on your pillow in the shower

About what percentage of your hair have you lost?

less than 10% 10% to 40% 40% to 70% over 70%

Describe the thinning areas of the scalp
“smooth,” no hair at all short “weak” hair
Have you tried any topical solutions for your hair loss?
Rogaine Propecia Others (specify)

What do you believe to be the major contributing factor(s) causing your hair loss?

hereditary stress poor diet lack of exercise
illness medication poor hair hygiene
other (specify)

 
Description of your hair and scalp
Describe the texture of your hair (select one or more)
normal oily dry thin/fine dandruff damaged brittle split ends
Do you:
swim blow dry your hair perm/colour treat it
If your hair is grey. how much ?
just starting less than 10% 10% to 40% 40% to 70% over 70%
Describe your scalp (select one or more)
tight loose seborrhea itchy psoriasis dry oily
What hair care product(s) are you currently using?

Description of your general health. Have you had any illnesses that you think might be affecting your hair?

Are you taking any medication that might be affecting your hair?
Are you taking any supplements and which ones?
Are you a vegetarian?
yes no

Do you exercise regularly?

yes no

Describe your ability to cope with stress:

poor average good

Are you currently experiencing a lot of stress?

yes no
Are you on a weight loss diet?
yes no
Have you lost a lot of weight recently?
yes no

Any questions or comments ?