Hair Consultation
Questionnaire
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1. Full Name
2. Age
3. Gender
Male
Female
Other
4. Contact Number
5. Email Id
5. How long have you been experiencing hair loss?
Less than 1 year
1–3 years
More than 3 years
6. What is the current status of your hair fall?
Minimal (occasional hair fall)
Moderate (visible thinning or shedding)
Severe (significant hair loss or bald patches)
7. Do you have a family history of hair loss?
Yes
No
Not Sure
8. Have you undergone a hair transplant before?
Yes
No
When?
9. What specific areas of hair loss concern you?
Scalp (e.g., front, crown, sides)
Beard
Eyebrows
Other
Please Specify
10. Are you taking any medications for hair loss?
Yes
No
Medicine Name
11. Do you have any pre-existing medical conditions?
Diabetes
Hypertension
Thyroid issues
Other
Please Specify
12. Do you smoke or consume alcohol?
Smoke
Alcohol
Neither
13. What are your expectations from the procedure?
14. Are you currently taking any blood-thinning medications?
Yes
No
15. Preferred Contact Method for Follow-up:
Call
WhatsApp
Submit Now
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ABOUT US
WHY NEW ROOTS
OUR EXPERIENCE
SERVICES
TEAM
LOCATIONS
REVIEW
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