Hair Health Diagnostics Questionnaire

Please complete the following form to help us understand your hair health and provide a tailored diagnostic service. All information is confidential and handled according to GDPR regulations.

1. Personal Information

Full Name:
Date of Birth:
Email Address:
Ethnicity:
Phone Number:
2. Medical History

Do you have any current or past medical conditions?
(Please specify):

Are you currently taking any medications or supplements?
(Please list):

Do you have any known allergies?
(Please specify):

3. Hair and Scalp Information

How would you describe your hair type?
(e.g., straight, curly, oily, dry):

Do you experience any of the following issues?
(Check all that apply):

Hair loss/thinning
Dry or itchy scalp
Dandruff
Excessive oiliness
Breakage or split ends
Other (please specify):

How long have you been experiencing these issues?

4. Lifestyle Factors

How many cigarettes do you smoke per day?
(If applicable):

How many hours of sleep do you get on average per night?

How would you describe your diet?
(e.g., balanced, high in fats, vegetarian):

Do you exercise regularly?
(Yes/No, if yes, how often?)

5. Previous Treatments

Have you previously sought treatment for hair issues?
(Yes/No, if yes, please describe):

Have you used any topical treatments or hair care products?
(Please list):

6. Diagnostic Goals

What are your primary concerns regarding your hair and scalp health?

What outcomes are you hoping to achieve from this diagnostic?

7. Consent

I consent to the processing of my personal data for the purpose of hair health diagnostics and follow-up.
(Yes/No)

I agree to receive communication related to my hair health diagnostics.
(Yes/No)

8. Additional Information

Is there anything else you would like us to know about your hair health?
Thank you for completing the questionnaire. We will review your responses and get back to you with further information.

GDPR Compliance Note:

Your personal data will be stored securely and used only for the purpose of providing hair health diagnostics.

You have the right to access, correct, or delete your personal data at any time.