Distance Assistance Questionnaire

Why not take advantage of this free hair/scalp assessment offer?

HAIR and SCALP ANALYSIS - "DISTANCE ASSISTANCE QUESTIONAIRRE"

Please tell us about yourself:
(DD/MM/YYYY)
The Hair
How Often?
Shampooing
Hair Loss
When you shampoo
On your pillow when you wake
Have you had a recent blood test ? It would make assessment easier if you obtained your test results and copied the results below.
Scalp
No
Yes
Please give details
No
Yes
No
Yes
Diet
If you are not sure please fill in a sheet of paper listing what you would normally eat in one
General Health
No
Yes
No
Yes
No
Yes
Sometimes
No
Yes
For Women Only
No
Yes
No
Yes
No
Yes
No
Yes
 

THE HAIR & SCALP CLINIC
TRICHOLOGY HOUSE
4 WARRINGTON ST
ASHTON UNDER LYNE
LANCASHIRE
OL6 6XB
 
TEL/FAX +44 (0)161 330 1547
 
E-Mail: info@trichology.co.uk

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