Hair Loss Questionnaire - HomeopathicVibes

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Our Address: 940 E El Camino Real, Sunnyvale, CA - 94087 | 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538

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Hair Loss Questionnaire

Why Me?

I'm providing homeopathic services for over 20 years in entire California. My clinic is located in Sunnyvale, Fremont, and San Jose. I have treated more than 1000 patients suffering from various conditions. I also provide online consultation if you're not able to visit any of my clinics. I have more than 100 five stars reviews on Google, Yelp, and other reviews websites. If you would like to know more about me, then feel free to reach me out by phone.

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Hair Loss Questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

Email *

When did first noticed the hair loss or thinning?

Less than a month.
More than a month.
More than month but less than year
More than year
Others

Does it affect the scalp alone, or does it occur elsewhere on the body?

Only scalp.
On the face.
Other parts of the body also.

Are the lost hair are?

In patches.
Diffusely ( evenly all over the scalp)

Have you been noticing lots of hair in the shower, tub, hair brush or on your pillow?

Yes
No
Always

Have you been noticing your hair are slowly thinning out over the time ?

Yes
No

Are you having anorexia, nausea, vomiting or upset stomach?

Yes
No

Any body in your family has had the similar pattern of hair loss?

Yes
No
Don’t know

Have you ever had jaundice, edema, hyper pigmentation, pallor, or duskiness?

Yes
No
Don’t know

Have you been ever had exposure to insecticides or pesticides?

Yes
No
Don’t know

Do you think you have been exposed to EMF’*s more than usual? ( *Electro magnetic frequencies)

Yes
No
Don’t know

Have you ever taken medications for over or under active thyroid?

Yes
No

Have you noticed decreased/increased libido or loosing interest in sex?

Yes
No

Do you use a hot blow dryer or electric curlers?

Yes once in a while
Daily
Never

Do you periodically dye, bleach, or perm your hair?

Yes
No
Always
Sometimes

Are you frequent to swimming pool or beach very often?

Yes
No

Do you have the habit of pulling the hair or twirling it around the fingers when nervous?

Yes
No

Have you been noticing white spots or pitting in your nails?

Yes
No

Are you having excessive stress?

Yes still have it.
Used to have it.
Sometimes
Never

Any recent weight changes?

Did not gain or loose any pound in last 6 months.
Did gain more than 10 lbs in last 6 moths.
Did loose more than 10 lb in last 6 moths.

What kind of shampoo, conditioner or cleansers you use please explain?

You are: Please pick the right choice.

Vegan
Vegetarian.
Non-Vegetarian.
Eat meat occasionally.
Others

How many serving of fruit and vegetables you eat daily?

Less than one serving or none daily
One to three servings daily
More than three but less than six.
More than six servings daily.

Do you do any walking or exercise?

Walk ____minutes ___times a week.
Exercise___minutes___times a week.

How many hours do you sleep?

5-6 hours each nigh
4-5 hours each night.
7-8 hour each night.
More than 8 hours.

Any other information you want to share regarding your health?

Phone

About Me

I have passion for homeopathy. I am blessed to be born in family of Homeopaths. My grand father Dr. Hazara Singh Gill was great homeopath of his times. He did his M.B.H (Bachelor of Medicine in Homeopathy) from Punjab Homeopathic Medical College Lahore in 1925.

Sunnyvale Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 940 E El Camino Real, Sunnyvale, CA 94087, United States
harminder@homeopathicvibes.com

Fremont Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538, USA.
harminder@homeopathicvibes.com

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Weekend: By Appointment only

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