ONLINE CONSULTATION If you are unable to visit the Centre, please feel free to complete the form below. Please try not to leave any questions unanswered. Important information regarding Online Consultation: In order to receive optimum benefit from treatment for your hair or scalp problem it is important to define the precise nature of the condition and the stage that the condition has reached. We therefore strongly recommend that you complete our carefully designed diagnostic form and send us a sample of 10 strands of your hair plucked from 5 different parts of your scalp(see the diagram below), with the roots in a paper pouch along with a photo of your scalp and the appropriate Demand Draft addressed to: RichFeel Trichology Centre, Ground Floor, Link-Komal Apts. Next to HDFC Bank, Linking Road, Santacruz West, Mumbai 54. The form will be examined by our Trichologists and Tricho analysis of your hair strands will be done under the Tricho Analyzer to know the exact state of your hair roots, the hair shaft, the protein content as well as the A/T ratio. After diagnosis and prognosis by the Trichologist, your Tricho Analysis report will be compiled and the appropriate internal and external treatment will be prescribed, this will be couriered to your doorstep. Consultation Charges and Mode of payment: Along with your hair samples and photo of your scalp, you need to send a demand draft of Rs.900/- addressed to `RichFeel Trichology Centre` payable at Mumbai. The above mentioned fee is inclusive of the Tricho Analysis report and courier charges and does not cover the cost of medication. Medications will be charged extra, the exact prescription details and details of the amount to be paid will be couriered along with the Tricho Analysis report. All payments must be made by a Demand Draft. Analysis and prognosis will be done subject to realization of the Demand Draft. Plucking 10 Hair Strands( 2 from 5 different parts of the scalp): CONSULTATION FORM (entries marked by * are compulsory)       PERSONAL DETAILS:        Salutation: Mr. Mrs. Ms.         *Name:       *Address: (full postal)       *E-mail:       Tel: Home-       Tel: Office-       Tel: Mobile-       Fax No. :       Height:       Age:       *Sex:  Male  Female       Occupation:       How did you hear about the RichFeel Trichology Centre?           What is your chief complaint?                 Health History:       Do you have any of the following conditions? Anemia Liver Problems Hormone Imbalance Migraine Prostate Problems Crohn`s disease Depression Malaria Thyroid Problems Jaundice Diabetes Dysentery Renal failure Typhoid Endometriosis none Polysystic Ovarian Syndrome Hypertension(High Blood pressure) Hypotension(Low Blood pressure) Other conditions or expand on previous answers:           Have you had any injuries/stitch marks on the scalp?   Yes No       Have you undergone any surgery/hospitalization in your lifetime?   Yes No       What stomach problems do you suffer from? Bloating Gas None Any Other:         How is your bowel movement?   Regular Irregular       Do you take any Prescription medicines?   Yes No If yes, name of the medicine:           Do you easily feel tired?   Yes No       Does your energy level fluctuate? Yes No Don't know       Are you under constant pressure or stress?   Yes No       Do you work in an environment that exposes you to chemicals on a daily basis?   Yes No       Do you have any other allergies, specially to lactose/drug reaction? Yes No Don't know       Are you suffering from irregular menstruation?   Yes No       What form of contraception do you use, if any? The Pill Other Barrier contraceptives(ie.condoms)     Do you suffer from headaches, dizziness?   Yes No If yes, how frequently:           Do you get any food cravings?   Yes No If yes, please mention how often:           Name the dental problem you suffer from, if any:           Do you feel thirsty quite often?   Yes No       Do you suffer from mood swings/fluctuations?   Yes No       Are you sensitive to heat or cold?   Yes No       How is your sleep? Sound Disturbed Insomnia Inadequate     Your skin is: Oily Dry Normal Combination           Dietary Information:       What type of diet do you have? Mixed diet Purely veg. diet Milk/cheese and veg diet Sugar/sugary foods diet Fish and veg diet Cereals Purely non-veg. diet Alcohol/smoking/drugs   Any Other:       How much water do you consume in a day?(litres)           Do you take any mineral or Vitamin supplements?   Yes No If yes, name of supplement:           Has your weight changed dramatically in the last 12 months? Weight loss Weight Gain No dramatic weight change           Nutritional Problems       Do you get bruised easily?   Yes No       Have you noticed any of the following symptoms lately? Muscle twitching Frequent infections Heart palpitation Fluid retention Poor memory Period cramps Light sensitivity/Sleep problems     What is your current blood pressure?(please have this measured by a reliable person i.e. your GP)           Do you suffer from blood pressure?   Yes No       If yes, are you under any medication?   Yes No       Which medicine do you take for Blood pressure?           Are you currently having treatment by chemotherapy and/or Radiation therapy?   Yes No       Do you have an iron deficiency or any other form of dietary deficiency? Yes No Unsure             Family History       Is there a history of hair loss in your family? If so, which family member(s)? Father Mother Grandparents Uncle Brother or Sister               Hair Loss       Where are you experiencing hair loss?       On the top of your head On the top and sides of your head(all over scalp) Is the hair loss sudden with smooth, round bald patches appearing in less than 3 months?       How long have you suffered with hair loss or thinning?   Please Select Less than 1 year Between 1 and 5 years Five years or more         Have you experienced total hair loss on your head?   Yes No       Have you experienced hair loss on your body or face?   Yes No       Is there an increase in the amount of daily hair loss? If so, is the increase in the number of hairs falling:   Please Select Less than fifty? Fifty to one hundred? One hundred and above?               Your Scalp       Is your scalp:- Flaky ? Itchy? Oily? Dry? Normal oiliness Prone to dandruff? Have spots or acne?     Does your scalp weep or is there a crust build up?   Yes No       Please describe any other symptom:                   Care of Hair and scalp       How often do you shampoo your hair?           How often do you oil your hair?           Do you use chemicals in your hair? e.g. bleach, mousse, hair colour, perm solutions, etc.   Yes No If yes, which ones and how often:           How do you dry your hair? Finger dry Blow dry-hot Blow dry-cold Others(please specify):           Are you an active swimmer?   Yes No       Do you expose your hair to sunlight?   Yes No       Any extra comments about your hair or scalp problem:           Please click here to read our Information and Privacy notice before continuing       By clicking Submit, I hereby state that all my answers to the above questions are true as to the best of my knowledge. Please read the above disclaimer before submitting the form.                     To book a Tricho-check call our Centre on 91-22-56778877. We are open 7 days a week.
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