SKIN & HAIR HEALTH ASSESSMENT

Basic Information

Full Name *

Age: *

Gender *

Location/City *

Occupation Type *

Skin Type & Concerns

How would you describe your skin type? *

Do you currently have any of the following skin concerns? * Acne/Pimples Pigmentation or Dark Spots Redness or Inflammation Fine Lines/Wrinkles Dark Circles Dull Skin Sunburn/Tanning Itching or Flakiness

Do you experience seasonal changes in your skin condition? *

How often do you use sunscreen? *

How often do you exfoliate or use scrubs? *

Hair Type & Concerns

What is your current hair type? *

Scalp Type: *

What hair issues are you currently facing? * Hair fall Hair thinning Dandruff/Flaky scalp Premature greying Split ends Frizzy hair Bald patches

How many strands do you estimate you lose per day? *

Is hair fall more in any particular area? *

Lifestyle & Health Factors

Do you follow a balanced diet? *

Do you take supplements (e.g., biotin, vitamin D, omega-3)? *

How often do you consume water daily? *

Do you smoke or consume alcohol regularly? *

Do you face high stress levels frequently? *

Do you have any of these medical conditions? * Thyroid PCOD/PCOS Diabetes Hormonal imbalance None

Are you currently on any medications that may affect your skin/hair? *

Have you had Covid or other major illness in the past 12 months? *

Product Usage & Routine

How often do you wash your face/hair? *

Which of the following do you use regularly? (Select all that apply) * Facewash Toner Moisturizer Sunscreen Serum Anti-acne/anti-aging cream Face mask/scrub

What kind of shampoo do you use? *

Do you use hair oil or hair serum regularly? *

Have you undergone any of the following treatments in the last 6 months? *