Have you noticed any changes in your hair recently?
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My hair looks normal, no changes
Reciding hairline or thinning at the crown
Sudden shedding all over
Small round bald patches
Thinning at the edges/hairline
Do you often wear tight hairstyles, braids, extensions, or hats?
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Yes
No
How long have you noticed hair loss?
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No changes
Less then 3 months
3-12 months
More than 1 year
Does hair loss run in your family?
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Yes
No
Not sure
How would you describe your stress levels in daily life?
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Low
Moderate
High
How many hours of sleep do you usually get per night?
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Less than 6
6-8
More than 8
How would you describe your diet?
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Balanced and healthy
Could be better
Poor (fast food / low nutrients)
How often do you use heat styling tools (blow-dryer, straightener, curling iron)?
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Rarely
A few times per week
Almost daily
Do you notice dandruff, itching, or scalp irritation?
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Yes
Sometimes
No
What’s your biggest goal for your hair?
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Prevent future hair loss
Regrow lost hair
Keep it strong and healthy
I’m not sure yet
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Full Name
Email
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