Get to know your health Do you have dandruff? No Yes, mild that comes and goes Yes, heavy dandruff that sticks to the scalp What are your major hair goals? Regrow hair Control hair fall I have a good set of hair, I want to maintain it Work on hair quality Delay greying Family history of Hair loss Mother or anyone from mother's side of the family Father or anyone from father's side of the family Both None How would you describe your hair loss to a doctor? Hair Clumps A Thinner Ponytail A Visible Scalp Lighter Weight Poor hair Growth Hair Breakage Bald Patches Which image best describes your hair loss? Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Coin Size Patch Heavy Hair Fall Across The Head Next Get to know your lifestyle How energetic do you feel? Always high Low when I wake up, but gradually increases Very low in afternoon Low by evening/night Always low How stressed are you? None Low Moderate(work, family etc ) High (Loss of close one, separation, home, illness) How well do you sleep? Very peacefully for 6 to 8 hours Disturbed sleep, I wake up at least one time during the night Have difficulty falling asleep Are you suffering from anemia (low haemoglobin) or any other vitamin deficiency? No Yes Not Sure Are you going through any of the stages below? Pregnant Post Pregnancy (Delivered in the last one year) Menopause None Could you be suffering through any of the below? PCOS Depression Hormonal Imbalance Thyroid None Do you feel constipated? No/Rarely Yes Unsatisfactory bowel movements Suffering from IBS (irritable bowel syndrome) /dysentery Previous Submit Form Submitted Successfully!We will contact you as soon as possible. Powered By
