Step 1: Personal Information
Full Name:
Email:
Sex:
Select
Male
Female
Other
Age:
Select
18-25
26-40
41-65
Phone:
Location:
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Step 2: Areas of Hair Loss
Where are you noticing changes to your hair?
Along the hairline
At the top
All over
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Step 3: Hair Type
What is your hair type?
Straight
Wavy
Curly
Coily
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Step 4: Noticing Changes
When did you start noticing changes to your hair?
1 month or less
2-3 months
4-6 months
More than a year
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Step 5: Hair Concerns
What hair problems do you face? (Select all that apply)
Hair fall
Slight hairline recession
Deepening hairline recession
Thinning or balding on the crown area
Scalp visibility with thinning at temples & crown
Dominant bald patches with visible scalp
Hair fall
Slight hairline recession
Deepening hairline recession
Scalp visibility with thinning at temples & crown
Dominant bald patches with visible scalp
Hair fall
Slight hairline recession
Deepening hairline recession
Scalp visibility with thinning at temples & crown
Dominant bald patches with visible scalp
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Step 6: Lifestyle & Diet
How often do you wash your hair?
Select
Daily
Every 2-3 days
Once a week
Rarely
Does hair loss run in your family?
How often do you tend to experience stress?
Select
Little
Moderate
Significant
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