Hair & Scalp Consultation

You can always press Enter⏎ to continue

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

21Questions

1
Could we please take your name?* This field is required.
First Name
Last Name
2
Please tell us your age* This field is required.
Under 18
18-35
35 - 50
50 +
3
Are you male or female?* This field is required.
Male
Female
4
Which image matches your hair loss?* This field is required.
Temples
Patches
Centre of Head
Widened Part
Forehead
Other
5
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
6
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
7
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
8
Do you have any children?* This field is required.
0-2 years old
3 years old +
No children
9
Have you had any major operations or illnesses in the last 4-6 months?* This field is required.
Yes
No
10
Rate your stress levels on a scale of 1-10* This field is required.1 being low stress, 10 being highly stressed
11
Is there a history of hair loss in your family?* This field is required.
YESNO
12
Are you taking any medication?* This field is required.
YESNO
13
Do you carry out any chemical treatments on your hair?* This field is required.I.e. relaxers, colouring
YESNO
14
Do you often wear hairstyles that cause tension on the scalp?* This field is required.I.e. braids, single plaits, weaves, wigs
YESNO
15
Do you wear wigs?* This field is required.
YESNO
16
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
17
Are you experiencing any of the following hair issues?* This field is required.
Dry, brittle hair
Hair breakage
Limp, gummy hair
None
18
Is there anything else you would like us to know?
Huge
Large
Normal
Small
Ok
Ok
19
How did you hear about St Claire's Hair?* This field is required.
20
You'll receive a full report via email* This field is required.Please enter your email address. *By completing this form you are signing up to receive our emails and can unsubscribe at anytime.
example@example.com
21
Please enter your phone numberWe send exclusive offers via SMS ONLY. You may opt-out at anytime
Should be Empty:

Question Label

1 of 21See AllGo Back