To assist me in improving my product range and to better understand your condition, I would be most grateful if you could complete the questionnaire following your enquiry. This information is purely for my own use and will be treated confidentially - Stan.
Please type your enquiry details in the box below:
Full Name:
E-mail address:
Questionnaire
What is your age, please?
What is the name of the shampoo you most often use?
What is the name of the conditioner?
Select your hair texture and condition:
How often do you shampoo your hair?:
Do you perm or colour your hair?:
Do you have any allergies - if so, to what?:
Do you take any medication(s) on a regular basis - if so, which one(s)?:
Have you been treated by a dermatologist for any skin problems - if so, what were the problems?:
Have you had any illness or surgery before you noticed hairloss? (please explain):
Is baldness hereditary in your family?:
If so, please explain:
Are you losing your hair:
How old were you when you first noticed that your were losing your hair?:
Did you have any scalp disease or dandruff when you started to lose your hair?:
Please explain:
Do you experience any burning, itching or tingling on your scalp? (please explain):
What type of sports activities do you participate in?:
Your full postal address:
Telephone including STD code:
Thank you
