Hair Loss

Are you experiencing hair loss..

• • On the top of your head only
  • On the top and sides of your head
    (all over scalp)
  • At the front (receding hairline)
  • At the back/vertex area
  • Is the hair loss sudden with
    smooth, round bald patches
    appearing in less than 3 months
• How long have you suffered with hair loss or thinning? Please select 5 years or more Between 2 and 5 years Between 1 and 2 years Less than 1 year
• Approximately how much hair are you left with on the head?
  • Under 25%
  • 25-50%
  • 50-75%
  • Over 75%
• Approximately how much hair are you left with in the affected areas?
  • Under 25%
  • 25-50%
  • 50-75%
  • Over 75%
• Have you experienced total hair loss on your head ?
  • Yes
  • No
• Have you experienced total hair loss on your face ?
  • Yes
  • No
• Have you experienced total hair loss on your body ?
  • Yes
  • No
• Is there a history of hair loss in your family? If so, which family member(s)?
  • Father
  • Mother
  • Grandparents
  • Uncle
  • Brother or sister
• Is your hair type :
  • Caucasian (White)
  • African
  • Asian
  • Other:

Your Lifestyle

• Is your general health and fitness: Please Select Very good Good Satisfactory Poor Very poor
• Are you under constant pressure or stress?
  • Yes
  • No
• Do you work in an environment that exposes you to chemicals on a daily basis?
  • Yes
  • No
  What type of chemical?
• Have you plaited or braided your hair in the past 5 years?
  • Yes
  • No

Hairstyle

• Do you use extensions or a weave-on ?
  • Yes
  • No
• Do you plait or braid your hair ?
  • Yes
  • No

Hair care routine

• How often do you wash your hair?
• Do you use chemicals on your hair? e.g. bleach, perm solutions, hair colourings, relaxers or any other.
  • Yes
  • • Which ones?
    • How often?
  • No

Your Scalp

• Is your scalp :
  • Flaky?
  • Itchy?
  • Dry?
  • Oily?
  • Normal?
  • Have spots or acne?
  • Prone to dandruff
• Does your scalp weep?
  • Yes
  • No
• Is there a crust build up on your scalp?
  • Yes
  • No
• Please describe any other skin problems on your body or face.

Medical Profile

• What is your current blood pressure level? (Please have this measured by a reliable person i.e. your G.P.)
• Have you had a blood test in the last 12 months?
  • Yes
  • No
• Do you have any of the following conditions?
  • Anaemia
  • Thyroid Problems
  • Liver Problems
  • Hormone Imbalance
  • Diabetes
  • Migraine
  • Prostate Problems
  • Renal Failure
  • Chron's Disease
  • Depression
  • Endometriosis
  • Polycistic Ovarian Syndrome
  • Hypertension (High Blood Pressure)
  • Hypotension (Low Blood Pressure)
  • Other conditions, or expand on previous answers ?
• Are you currently having treatment by chemotherapy and/or radiation therapy?
  • Yes
  • No
  Please give details of the treatment?
• Do you take any prescription medicines?
  • Yes
  • No
  • Please give details of medicine and expected duration.
• Do you have an iron deficiency, or any other form of dietary deficiency?
  • Yes
  • No
  • Unsure
  Please give details of the deficiency?
• Do you have an allergy to lactose?
  • Yes
  • No
• Do you have any other allergies?
  • Yes
  • No
  • If yes, please give details of your allergies.
• Have you used any medication or treatment for your hair loss or scalp conditions in the past?
  • Yes
  • No
• If you have used any of the treatments listed below for hair loss or a scalp problem please let us know:
  • Nourkrin
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Procerin
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Provillus
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Revivogen
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Regaine Liquid
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Regaine Foam
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Propecia
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Other Treatment 1
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Other Treatment 2
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
  • Other Treatment 3
  • How long for? 0-3 months       4-7 months    More than 7 months   
    How did it work? Thickened the hair a lot    
    Thickened the hair a bit
    Stopped my hairloss         
    Slowed my hairloss
    Did not work at all
    Were you using any other hair loss treatments at the same time? Yes    No
    
    What was the name of the treatment?
• Have you received treatment or advice from :
  • Trichologist
  • Hair dresser
  • Dermatologist
  • G.P.
  • Other
  • If yes, what advice ?
• What form of contraception do you use, if any?
  • The Pill
  • Barrier Contraceptives (ie condoms)
  • Other
• Have you recently given birth?
  • Yes
  • No
• Do you breast feed?
  • Yes
  • No
• Women – have you, or anyone in your immediate family suffered from breast cancer?
  • Yes
  • No
  If yes - Please give details
• Are you, or is your partner currently pregnant ?
  • Yes
  • No
• Will you be trying for a child in the next 12 months?
  • Yes
  • No
• Have you had a raised temperature/fever due to illness in the last 3-6 months?
  • Yes
  • No

Dietary Habits

• What type of diet do you have?
  • Mixed Diet
  • Lacto Vegetarian (milk/cheese and vegetarian diet)
  • Piscatarian Diet (Fish and Vegetarian Diet)
  • Vegan (Purely Vegetarian)
  • Other
• Do you take any mineral or vitamin supplements?
  • Yes
  • No
  • If yes:
• Has your weight changed dramatically in the last 12 months?
  • Weight Loss
  • Weight Gain
  • No Dramatic Weight Change
  How many kgs / Lbs, over how long?