Personal Details
Q.1 Is the problem you’re seeking help for:
Q.2 When did the hair loss start or first become noticeable to you?
Q. 3A Please choose which category is most similar to your own:
If you answered "YES" to Q.3-3A, please disregard Questions 5 & 9.
Q. 7 Is there any accompanying ‘eruptions’ on your scalp, such as:
Q. 11 If so, what are you allergic to? (please indicate which foods, medications &/or environmental allergens)
Q. 13 Do you take any prescribed medications or vitamin/mineral/herbal supplements of any kind?
(please state what drug/s or supplements, the daily dosage you take, & for how long you’ve been taking them)
Q. 14 Do you use any illicit/recreational drugs of any kind?
(please state what drugs, the average amount you’d use daily, & for how long you’ve been using them)
Q. 16Do you regularly consume alcohol? If "YES", what form of alcohol and how many standard drinks on an average day?
(please state what drugs, the average amount you’d use daily, & for how long you’ve been using them)
Q. 16ADo you consider yourself a BINGE DRINKER? If "YES", is this only at weekends or do you drink constantly ?
(please state what drugs, the average amount you’d use daily, & for how long you’ve been using them)
Q. 18ADo you consume a special type of diet, eg: vegetarian, gluten-free, carbohydrate-free, high protein etc.
Q. 19Describe an average day’s diet for you (breakfast, lunch, dinner, snacks)
Q. 20What FLUIDS would you consume on an average day, and how many of each: (water, juices, coffee, tea, cola or other caffeinated drinks)
Q. 21Do you ‘crave’ sugary/refined foods or caffeinated drinks? If "YES" please detail:
Q. 22aDo you feel most tired or are your energy levels lower in the morning or in the afternoon?
Q. 26What do you do to relieve these negative emotions?
Q. 27 Are you able to get some daily or weekly exercise? If so what: ?
Q. 28 Do you regularly experience disturbed sleep patterns?
If "YES", why do you think this occurs?
Q. 29 How often do you wash your hair ?
Q. 29A What shampooing and/or grooming products do you use (Brands)?
Thank you for your time and patience in completing this questionnaire. When you have submitted this consultation you will be automatically taken to a secure payment form.