Beijing 101 Hair Consultants  |  Hair Loss

ALL INFORMATION GIVEN BY YOU WILL BE KEPT STRICTLY CONFIDENTIAL.

(A) Personal Particulars

Do you live in Singapore?  Yes    No

Name:

*

Age (please provide us with your age as of today):   1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100 Above 100

Contact No.(1):

+65 - *

Contact No.(2):

+65 -

*These are required fields.

(B) Hair/ Scalp Condition

2)   How many strands of hair do you lose a day?

       1-100 100-150     Not Sure

3)   How long have you been suffering from this condition?

       0 1 2 3 4 5 6 7 8 9 10 11 12  Month     0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30  Year

(C)   Medical History

1)   Are you suffering from any illness?   Yes    No

      Name of illness:   

2)   Are any of your family members suffering from baldness/thinning hair?
      Yes    No

3)   Have you been treated by any doctor or hair care centre for your hair/scalp problem?
      Yes    No

(D)   Lifestyle

1)   Your occupation:   Working Indoor Working Outdoor Student Housewife Retired

(E)   Preferred time for us to contact you :   10:30am to 12:30pm 12:30pm to 2:30pm 2:30pm to 4:30pm 4:30pm to 6:30pm 6:30pm to 7:30pm