Online diagnosis

To assist with the diagnosis, please enter any information as accurately and honestly as possible, Once submitted, Emil will contact you with a diagnosis and recommendations for treatment.

All information will be treated with the strictest confidence.

Name:
Telephone
Email address
Section 1 - washing your hair
How often do your wash your hair per week?
Why?:
Section 2 - hair and scalp condition
Are the roots of your hair:
Are the tips of your hair:
Is your scalp sensitive or irritated?:
Do you have dandruff?:
If you have dandruff, does it fall on your shoulders?:
Do you have problems with itchyness?:
Please give details of any products you have tried to relieve the dandruff or itchyness :
Section 3 - hairloss
Are you losing your hair:
Do you find a lot of hair at the bottom of the bathtub ?:
Do you feel that your hair is thinning?:
What is your hair like 48 hours after washing?:
Section 4 - about your hair
What colour is your hair?:
What texture is your hair?:
What's the appearance of your hair?:
Have you had on of the following done over the last 3 months (check all that apply)?:
   
Have you been in the sun recently ?:
Have you been swimming in the sea or a swimming pool recently?:
Section 5 - Health \ Lifestyle
In your opinion, do you have a good diet?:
Do you have any health problems at the moment ?:
Are you taking any medication ?:
In your opinion, do you have a relaxed lifestyle?:
Have you recently suffered any physical trauma (e.g. childbirth, anesthesia) ?:
Have you suffered from a psychological trauma (e.g. depression, stress)?:
Please enter any information you feel relevant to assist with our diagnosis:
 
 


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