Patient Name
Age
Gender MaleFemale
Contact No.
Date
Primary Concern Hair FallThinningBald PatchesReceding HairlinePoor GrowthGreyingDandruff / ItchingOther
If Other, specify
Duration Less than 3 months3–6 months6–12 monthsMore than 1 year
Nature SuddenGradualSeasonalProgressive
Daily Hair Fall Less than 5050–100More than 100Clumps
Area Involved FrontCrownTemplesDiffusePatchy
Hair Thinning Noticed YesNo
Dandruff YesNo
Itching / Redness / Pain YesNo
Scalp Type OilyDryNormal
Medical Conditions ThyroidPCOSDiabetesAnemiaAutoimmunePost-COVIDOther
Currently on Medications / Supplements YesNo
Illness / Surgery in Last 6 Months YesNo
Menstrual Cycle RegularIrregular
Pregnancy / Delivery in Last 1 Year YesNo
Breastfeeding YesNo
Family History of Hair Loss FatherMotherBothNone
Diet VegetarianNon-VegetarianVegan
Protein Intake AdequateInadequateNot Sure
Water Intake Less than 2L2–3LMore than 3L
Stress Level LowModerateHigh
Sleep Less than 6 hours6–8 hoursMore than 8 hours
Hair Wash Frequency DailyAlternate days2–3 times/weekWeekly
Hair Products Used ShampooConditionerMaskOilSerum
Chemical Treatments in Last 1 Year
Treatments Taken Earlier PRPGFCMesotherapyMinoxidilFinasterideSupplementsHome RemediesNone
Response GoodModeratePoorNo Improvement
What do you expect from treatment? Reduce hair fallRegrow hairImprove densityImprove qualityMaintenance & prevention
Select Course*MicrobladingPowder BrowsWatershine BB GlowLip MicropigmentationScalp MicropigmentationEyelinerMasters CourseOther
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