This form is in html format. It can be sent back in text format also. I have been using this form since 19 years. For the web, it has been slightly modified in May 2010

Please provide relevant details / answers to get the Scientist's views. You can send the form  by e mail or post, after making the necessary payment for consultation.

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

          ..................................................................


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




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

Section 3:   Dandruff

a) Do you suffer from Dandruff now ? Yes / no.

b) If yes, the period of sufferance:   From age ....to ....

c] Do you sweat much on the head ? yes / no

d] The impact of dandruff on your hair, as per your assessment


Section 4: Hair Dressing

a] Do you apply Hair Oil / Cream for the hairs? Yes / No
b] If no, at what age, did you stop the use? age ....yrs

Section 5: Do you use shampoos now ? Yes or No


a] Any benefit apart from cleaning convenience ?

b] any other connected detail

Section 6: The Hair History

Your age when hairloss started ..... years.

Remedies / Cures tried to delay or avoid the hairloss / thinning process -
Please describe all the relevant things in your own way



Section 7: Hair / Thinning History in the family [ provide details only if relevant ]

Section 8: Hereditary Baldness: [ provide details only if this factor has relevance ]

Section 9: Remedial Steps taken and the positive or negative effects so far [ Maximum 10 lines  - in your words ]




Section 10] Any other detail that you think has relevance for your hair problem [ Maximum 10 lines  - in your words ]






Signature

Date        


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 19 years interactions with hairloss sufferers who have contacted me and my academic research of dermatological details. Please seek medical counsel as an additional step

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 used 'users records' in the past
Refer youngsters pages for our presentation method over the years

 

For hairloss control, Dandruff Remedy and hair gain:    Site map 1   Hair Consultation   Supply   Contact

Haircare:  Tips for the Top...RUfooled...Social Subjects...spicy shots   Others: Major links are at the top of each page   .

Errors and Omissions exempted.  If there be any unwanted oversights, mistake in content or suggestions for improvements, please e mail us

Main / original content:  2001: Last minor modifications: June 19, 2010:     Personal website of R. Ranganathan M.Sc., [ MBA - IIMA]