Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1About You2Hair Health3Your LifestyleYour NamePhone NumberEmail *How old are you?Gender *MaleFemaleNextWhich image best describes your hair loss? *Stage-1Stage-2Stage-3Stage-4Stage-5Stage-6Coin Size PatchHeavy Hair FallDo you have a family history of hair loss?Mother or anyone from mother's side of the familyFather or anyone from father's side of the familyBothNoneHave you experienced any of the below in the last 1 year? *NoneSevere Illness (Dengue, Malaria, Typhoid or Covid)Heavy weight loss / heavy weight gainSurgery / heavy medicationSelect at least one optionNextHow well do you sleep?Very peacefully for 6 to 8 hoursDisturbed sleep, I wake up at least one time during the nightHave difficulty falling asleepHow stressed are you?NoneLowModerate(work, family etc )High (Loss of close one, separation, home, illness)Do you feel constipated?No/RarelyYesUnsatisfactory bowel movementsSuffering from IBS (irritable bowel syndrome) /dysenteryHow are your energy levels?Always highLow when I wake up, but gradually increasesVery low in afternoonLow by evening/nightAlways lowSubmit
