Civility

Mrs.
Mr.

First name

Name

Telephone

Email

Age

Height (cm)

Weight (kg)

Address

Postcode

City

Country

Is your hair falling out too much at the moment?

Yes
No

Intensity of your hair loss :

Low
Strong

The rate of hair loss :

In fits and starts
Continuous

Anything else you'd like to tell us?

Density

Density of my hair in detail :

All over your head

On top

At the back (tonsure)

On the temples

On the frontal area

Nature of your hair

Natural
Coloured
Straightened
Frizzy

Have you ever braided your hair? Added to it?

Yes
No

Do you notice any hair loss as a result of these hairstyles?

Yes
No

You're wearing a wig:

Never
Sometimes
Often

Do you suffer from dandruff?

Yes
No

Do you have any itching?

Yes
No

Do you suffer from a scalp condition such as eczema, dermatitis or psoriasis?

Yes
No

Do you apply Minoxidil?

Yes
No

How often?

Every day
2 or 3 times a week
Once a week
Less often

Are you taking any medical treatment?

Yes
No

Another health problem?

Do you think you are prone to stress?

Yes
No

I agree that the Centre Clauderer may keep my details for as long as is necessary to process my application, in accordance with the General Data Protection Regulation (GDPR).

Yes
No

Step 1: Completing the questionnaire

Civil status

My hair problems

Density

My hair

My scalp

Shampoo

My health

Gynaecology

Validation