Hair & Scalp Consultation

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Hair & Scalp Consultation

Hair & Scalp Consultation

We're going to ask you some brief questions about your health and hair loss in order to assess whether our products are right for you or if you should book a further consultation with your GP and/or Trichologist

20Questions

1
Please tell us your age* This field is required.
Under 18
18-35
35 - 50
50 +
2
Are you male or female?* This field is required.
Male
Female
3
Which image matches your hair loss?* This field is required.
Temples
Patches
Centre of Head
Widened Part
Forehead
Other
4
When did you first notice hair loss?* This field is required.
I have not noticed any hair loss
Over the last few days/weeks
Gradually over the last few months
Gradually over the last few years
5
Have you noticed hair loss on any other parts of your body?* This field is required.
Eyebrows
Armpits and Pubic Region
Arms and Legs
None
6
Are you experiencing any of the following scalp issues?* This field is required.
Pain, itching, burning or bumps on the scalp
Dandruff
Red/Dark brown/Purple dry scaly patches or ring-like patches,
None
7
Do you have any children?* This field is required.
0-2 years old
3 years old +
No children
8
Have you had any major operations or illnesses in the last 4-6 months?* This field is required.
Yes
No
9
Rate your stress levels on a scale of 1-10* This field is required.1 being low stress, 10 being highly stressed
10
Is there a history of hair loss in your family?* This field is required.
YESNO
11
Are you taking any medication?* This field is required.
YESNO
12
Do you carry out any chemical treatments on your hair?* This field is required.I.e. relaxers, colouring
YESNO
13
Do you often wear hairstyles that cause tension on the scalp?* This field is required.I.e. braids, single plaits, weaves, wigs
YESNO
14
Do you wear wigs?* This field is required.
YESNO
15
Which of these best describes your diet?* This field is required.
Balanced (fruits, veg, poultry, fish, dairy, grains)
Mixture of unprocessed & processed foods
Mostly processed foods
Vegan
16
Are you experiencing any of the following hair issues?* This field is required.
Dry, brittle hair
Hair breakage
Limp, gummy hair
17
Is there anything else you would like us to know?
Huge
Large
Normal
Small
Ok
Ok
18
How did you hear about St Claire's Hair?* This field is required.
19
You'll receive a full report via email* This field is required.Please enter your email address. We may send you special offers and unique information via email. You may opt-out at any time
example@example.com
20
Please enter your phone number* This field is required.We send exclusive offers via SMS ONLY. You may opt-out at anytime
Should be Empty:

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