Hair Care Survey

How much hair do you lose daily? * 30-100 strands (normal shedding) 100-150 strands (mild hair fall) 150-200 strands (moderate hair fall) 200+ strands (severe hair fall)

Where is the hair loss most noticeable? * Crown/top of the head Hairline/temples (receding) Overall thinning across scalp Patchy/circular bald spots No specific pattern

How long have you been experiencing hair fall? * A) Less than 3 months 3-6 months 6-12 months More than 1 year

What is your scalp type? * Normal (not too oily or dry) Oily/greasy Dry/flaky Combination (oily roots dry ends)

Do you experience any scalp issues? * No issues Dandruff/flaking Itching/irritation Redness/inflammation Burning sensation

How often do you wash your hair? * Daily Every 2-3 days Once a week Less than once a week

What is your hair texture? * Fine/thin Medium Thick/coarse Curly/wavy

Have you noticed changes in hair texture? * No change Hair has become thinner/finer Hair has become dry/brittle Hair has become more fragile/breaks easily

Do you see hair breakage? * No breakage Minimal breakage Moderate breakage at mid-lengths Severe breakage near roots

What is your stress level? * Low/minimal stress Moderate stress High stress (work/personal issues) Very high stress (major life events)

Have you experienced any of these recently? * A) Major illness or surgery Significant weight loss (10+ kg) Childbirth/pregnancy High fever or infection None of the above

How would you rate your diet? * Balanced with proteins vitamins minerals Vegetarian/vegan Low protein intake Irregular meals/poor nutrition

Do you take any medications regularly? * No medications Birth control pills Blood pressure/heart medications Thyroid medications Antidepressants/anxiety medications

What chemical treatments have you had in the past 6 months? None Hair coloring Straightening/rebonding Perming/curling Multiple treatments

How do you usually style your hair? Loose/natural Tight ponytails/buns Braids Hair extensions/weaves

How often do you use heat styling tools? * Never/rarely 1-2 times per week 3-4 times per week Daily

Is there a family history of hair loss? * No family history Mother side Father side Both sides

For women: Are you experiencing any hormonal changes? * No hormonal changes Menstrual irregularities PCOS/hormonal imbalance Menopause/perimenopause Postpartum period

Have you noticed any other symptoms? * No other symptoms Fatigue/tiredness Weight gain/loss Skin changes (acne dryness) Irregular periods (for women)

What is your water quality? * Soft water Hard water Chlorinated water Not sure