Hair Fall Assessment

Patient Details

Patient Name

Email ID

Age

Gender

MaleFemale

Contact No.

Date

Main Concern

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

Hair Fall Pattern

Daily Hair Fall

Less than 5050–100More than 100Clumps

Area Involved

FrontCrownTemplesDiffusePatchy

Hair Thinning Noticed

YesNo

Scalp & Hair Health

Dandruff

YesNo

Itching / Redness / Pain

YesNo

Scalp Type

OilyDryNormal

Medical History

Medical Conditions

ThyroidPCOSDiabetesAnemiaAutoimmunePost-COVIDOther

If Other, specify

Currently on Medications / Supplements

YesNo

Illness / Surgery in Last 6 Months

YesNo

Female-Specific (If Applicable)

Menstrual Cycle

RegularIrregular

Pregnancy / Delivery in Last 1 Year

YesNo

Breastfeeding

YesNo

Family History

Family History of Hair Loss

FatherMotherBothNone

Lifestyle & Nutrition

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 Care Practices

Hair Wash Frequency

DailyAlternate days2–3 times/weekWeekly

Hair Products Used

ShampooConditionerMaskOilSerum

Chemical Treatments in Last 1 Year

Previous Hair Treatments

Treatments Taken Earlier

PRPGFCMesotherapyMinoxidilFinasterideSupplementsHome RemediesNone

Response

GoodModeratePoorNo Improvement

Patient Expectations

What do you expect from treatment?

Reduce hair fallRegrow hairImprove densityImprove qualityMaintenance & prevention