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Prediagnosis
Please, fill this form to know your pathology and advise you a treatment. Thank you.
Kind of hair
Scalp
Eventual Transformations
Very fine
Very dry
Natural Hair
Fine
Normal
Colored Hair
Medium
Not very greasy
Bleached Hair
Soft
Very greasy
Soft Permed Hair
Strong
Irritated
Strong Permed Hair
Resistant
Psoriasis
Streaked Hair
Brittle
Seborrheic dermatitis
Silver Hair
Greasy
Deficiency
Type of deficiency
Type of shampoo, trademark and wash frequency
Hair loss
Light
Type
Seborrhoea
Medium
Trademark
Dry Dandruff
Hight
Frequency
Greasy Dandruff
% hair loss
Actualy your hair are
Complementary reports (about the customer)
Permed
Well-ballanced apperance
Age
Bleached
Sensitive apperance
Profession
Colored
Man
Woman
Some Causes of Baldness
Previous treatments
Stress, depression, nerves
By yourself
Vitamin deficiency or anemia
By other method
Postnatal o miscarries
Medical's treatments - Chemotherapy and Radiotherapy
Weight reducing treatment
Illnesses that cause fever
Hormonal Problems
Menopause
Traumatisms or recent operations
Menstrual disoreder
Mouth infections or other infections
Gastrointestinal disease or liver disease
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Name
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Email
Comments
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Obligatory field
True-life Story
Patient's diagnosis
Introduction to Dermotricology
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