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When do you see the most hair fall?
While washing my hair
While combing or brushing
After drying my hair
At all of these times
How much hair fall do you notice?
Mild
Moderate
Heavy
Which sounds most like you?
I feel active and energetic most of the day
I get tired faster than before
I feel low in energy by afternoon
Even normal daily work makes me feel tired
Do you feel empty, lighter after using the toilet?
Which describes you best?
Once a day and I feel completely clear
Twice a day and comfortable
My bowel timing is not regular
I go, but still do not feel completely empty
How often do you get gas, bloating or frequent burping?
Rarely or never
Sometimes after certain foods
A few times every week
Almost every day
Which describes your sleep best?
I sleep 7–8 hours and wake fresh
I wake up many times during the night
I keep thinking when I am trying to sleep
I find it hard to fall asleep or stay asleep
How often do you feel worried, restless, stressed or unable to switch off your mind?
Rarely
Sometimes
Often
Almost every day
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Name
Age
Sex
Select
Male
Female
Do not want to disclose
Email address
Phone
WhatsApp No:
Same as phone
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