1.Your Self
Sex	:	--- Male female *
Marital status	:	--- married UnMarried *
Designation	:	[Select One] Officer/Executive-Senior Officer/Executive-Middle Officer/Executive-Junior Software Professional Supervisor Clerical/Salesperson Self Employed Professional Businessman/Industrialist with 10+ employees Businessman with 1-9 employees Shopowner Student Not working/Retired Housewife Others *
Health (any Major illness)	:
Medication taken	:
2.Your Hair/Scalp
How long since first noticed abnormal hair loss?	:	--- Below 1 Month 1 Month 2 Months 3 Months 4 Months 5 Months More than 5 Months *
How many hair strands fall daily (now)?	:	--- Below 10 10 To 20 More than 20 *
Any known bald patches ?	:	--- Yes No *
Any Medical diagnosis done?	:	--- Yes No *
Any Abnormalities on scalp?	:	--- Yes No *
3.Your Diet
Vegetarian ?	:	--- Yes No *
High Consumer of meat?	:	--- Yes No *
High consumer of Seafood ?	:	--- Yes No *
Consumption of water no. of glasses /day ?	:	--- One Glass Two Glasses Three Glasses Four Glasses Five Glasses Seven Glasses Eight Glasses More than Eight Glasses *
Average food intake daily/mostly.	:	A. Steamed   B. Fried    C. Others *
4.Your Life Style
Do you work late (After 8.00PM) ? (On the average )	:	--- Yes No *
Do you sleep late (After 1.00AM)? (More then 3 days a week)	:	--- Yes No *
Do you drink excessively (More than 3 pints of beer/daily)?	:	--- Yes No *
Do you smoke excessively ?	:	--- Yes No *
Does your work stress you up ?	:	--- Yes No *
Would you consider your family life as being happy ?	:	--- Yes No *