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Trichology Form
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Email address
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Your answer
Name
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Your answer
Surname
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Your answer
Address
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Your answer
Post Code
*
Your answer
City
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Your answer
Country
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Your answer
Nationality
*
Your answer
Profession
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Your answer
Age
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Your answer
Phone number
*
Your answer
How did you know about us?
*
Your answer
How would you describe your lifestyle?
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Sedentary
Active
Outdoor
Confined
Required
Comments about above
Your answer
Physiopathology
*
Digestive system
Circulatory system
Respiratory system
Excretory system
Illnesses suffered
Hypertension
Family history
Medication
Allergies
Diabetes
Asthma
Anxiety
Depression
Stress
Celiac
Other
None
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Comments about above
Your answer
How is your diet?
*
Good
Not good
Vegan
Vegetarian
I'm taking vitamins
Other
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Comments about above
Your answer
Hair Texture
*
Thick
Normal
Thin
Hair Flexibility
*
Good
Normal
Rigid
Sebo-hydration
*
Oily
Normal
Dry
Scalp disorder
*
Psoriasis
Ezcemas
Seborrehic Dermatitis
Sensitive skin
Not sure
None
Required
Do you have same disorder spreading on other part of your body?
Your answer
Symptoms
*
Itching
Tingling
Sore
None
Other
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Comments about above
Your answer
How often do you wash your hair a week?
*
1
2
Every second day
Every day
How often do you dye your hair?
Your answer
Dandruff (pityriasis)
*
Greasy
Dry
Light
Build-up
Tear ducts
Adhered
None
Required
Hair loss/Alopecia
*
Long-standing
Sudden
Copious
Constant
Periodic
Progressive
General
Local
None
Gender
*
Female
Male
Prefer not to say
Please if you are female tell us about follows
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Menopause or premenopause
Pregnancy
Breastfeeding
Anticonceptives
Thyroid
Unregular period
None
Other
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Comments about above
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I give my consent to treat my all details in this form just regarding to this issue
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Yes
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