Name *

Phone *

How old are you? *

Gender *

What does your hair look like naturally? *

Describe your hair quality *

Do you feel like you're facing Hair Fall more than usual? *

Your hair widening stage *

What does a single strand of your hair feel like? *

Is hair loss a genetic issue in your family? *

Duration of Hair Fall? *

Describe your dandruff. *

Blood Pressure *Normal (110/70 to 130/80 mm Hg)Low (Below 100/60 mm Hg)High (140/90 or more mm Hg)Select your blood pressure level

Upload scalp image *

Upload your scalp image from all sides

Are you going through any of these stages? *

Are you taking any Prenatal or routine Vitamins? *

How well do you sleep *

How stressed are you *

Do you Smoke? *

Describe your energy levels *

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