Full Name

Email Address

Address Line 1

Address Line 2

Town / City

Postcode

Gender Gender Male Female Non-binary

Is your hair thinning/shedding? Is your hair thinning/shedding? Yes No

Where are you experiencing thinning/shedding? Where are you experiencing thinning/shedding? All over Top of head Around the hairline In patches

Have you experienced hair loss before? Have you experienced hair loss before? Yes No

How long have you been experiencing hair loss? How long have you been experiencing hair loss? Less than 6 months 6 - 12 months 1 - 2 years Over 2 years

Do you experience hair loss elsewhere on the body? Do you experience hair loss elsewhere on the body? Yes No

Briefly outline where you also experience hair loss.

Does your hair easily break/snap? Does your hair easily break/snap? Yes No

Is your scalp: Is your scalp: Itchy Sore / painful Oozing / weeping Flakey / scaling None of the above

Are you on any kind of diet? Calorie controlled or specific e.g. vegetarian. Are you on any kind of diet? Calorie controlled or specific e.g. vegetarian. Yes No

Briefly outline the diet you are on.

Are you currently: Are you currently: Receiving any medical treatment? Taking any medication - last 5 years? Pregnant - or recently pregnant? Taking a contraceptive pill or hormone replacement therapy? None of the above

Have you recently undergone any kind of: Have you recently undergone any kind of: Surgery Dental work Accidents causing physical harm Periods of stress None of the above

Have you ever had: Have you ever had: Allergies? Irritable Bowel Syndrome? Eczema? Hay fever? Asthma? Psoriasis? High fever? No of the above

Do you ever have chemical hair treatments? Do you ever have chemical hair treatments? Yes No

When was the last time and how regularly do you such treatments?

Have you had a ‘bad reaction’ to a chemical hair treatment? Have you had a ‘bad reaction’ to a chemical hair treatment? Yes No

Anything else you would like to add?