This form is in html format. It can be sent back in text format also. For the web, it has been slightly modified in May 2010. You can send the form  by e mail or post, after making the necessary payment for consultation.

Consultation charges:  Rs 150/ only for e mail replies: Add Rs 30 extra for reply by post: Refer the Consultation page for sending the payment and other details

 

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The identity, address and other personal details are intended only for our records and will be kept confidential. Score out or delete what is irrelevant for you, while filling the form.

Name and Address ...................................................................Gender

.............................................................................................present Age

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Section 1: Brief Description of the Hair Problem in your own words [ Maximum 10 lines  - in your words ]




Section 2: Your presumed causes for the present problem   [ Maximum 10 lines  - in your words ]

Section 3:   Dandruff

Do you suffer from Dandruff now ? Yes / no.  If yes, the period of sufferance:   From age ....to ....: Steps taken to overcome the problem

Section 4: styling

Do you apply Hair Oil / Cream for the hairs? Yes / No   If not, why not ? when was it stopped ?

Section 5: Do you use shampoos now ? Yes or No    Any benefit apart from cleaning convenience ?   any other connected detail

 

Section 6: The Hair History

Please describe  Remedies / Cures tried to delay or avoid the hairloss - Plus and minus points




Section 7: Hereditary Baldness: [ provide details only if this factor has relevance ]  [ 10 lines maximum]

Section 8: Remedial Steps taken and the positive or negative effects so far [ Maximum 10 lines  - in your words ]








Signature

Date 

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Note:  1]  I am a hair scientist and not a medical practitioner. The views should be taken accordingly. The views / analysis will be based on my 20 years interactions with hairloss sufferers who have contacted me and my academic research of dermatological details.

2]  Your identity and all the personal details / answers to the above questions, will be kept confidential for our records. The general details about hair problems may be used by us for research / presenting some findings, with abbreviated initials, without disclosing the identity. Name, address, phone number and e mail id will never be used in the site. You can check the site to note the way we have used them in the past
 

 

	Errors and Omissions exempted.  If there be any unwanted oversights, mistake in content or suggestions for improvements,  I will be thankful for your feedback
	Personal website of R. Ranganathan M.Sc., [ MBA - IIMA]    Main / original content: around 2002: last minor modification, Jan 7, 2012.    Contact