E-Consultant
1.Your Self
  • Name*
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  • E-mail*
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Phone*  
  • Address
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  • Sex*
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  • Marital Status*
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  • Designation*
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  • Health (any major illness)
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  • Medication taken
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2.Your Hair/Scalp
  • How long since abnormal hair loss first noticed? *
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  • How many hair strands fall daily (now)?*
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    Any known bald patches? *
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  • Any medical diagnosis done?*
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  • Any abnormalities on scalp?*
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3.Your Diet
  • Vegetarian?*
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  • High consumer of meat?*
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  • High consumer of seafood?*
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  • Consumption of water (no. of glasses/day)?*
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  • Average food intake daily/mostly.*
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4.Your Lifestyle
  • Do you work late (after 8.00PM)? *
    (on an average)
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  • Do you sleep late (after 1.00AM)?*
    (more than 3 days a week)
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  • Do you drink excessively (more than 3 pints of beer/daily)?*
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  • Do you smoke excessively?*
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  • Does your work stress you up?*
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  • Would you consider your family life as being happy? *
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