Since how long have you have been having hair fall ?WeeksMonthsYearsNot sure
Did the hair fall start after any illness? (If yes, then please mention the illness in the 'more information' column at the end of the questionnaire)YesNoNot Sure
Is there a family history of baldness/hair fall?YesNoNot Sure
Has the hair fall started after child birth/delivery?YesNoNot Applicable
Has the hair fall started after shifting to a new home /city?YesNo
Are you ,or have you been going through a lot of stress?YesNoNo Sure
Are you also losing hair in patches (alopecia) ?YesNoNot Sure
Is your menstrual cycle regular ? (If not, then please mention in detail about it in the 'more symptoms' column at the end of the questionnaire)YesNoNot applicable
Do you have dandruff (scales or powdery substance on the scalp) ?YesNoOccasionally
Have you got any investigations done? (If yes, then please mention any reports like thyroid or blood sugar in the 'more symptoms' column at the end of the questionnaire)YesNo
Are you already a patient with Dr.Manoj's Homeopathy? If yes, then give your Registration Number in the text box.YesNo
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