Ninian Smith, Consultant Trichologists, Hair & Skin Centre
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HAIR ANALYSIS FORM

Please printout & email, fax or post this form to us

Hair Sample Instructions

Pluck a sample of hair from the scalp (using fingers or tweezers), from an area of scalp near the problem area. This is important as a sample from a different area of the scalp may give a misleading result. We need at lease 10-20 hair bulbs for an accurate analysis. These should be growing hair NOT hair that has already fallen. The hair sample can then be wrapped in paper and placed in an envelope together with the hair analysis form and analysis fee of £12.50 and send to the address below. Alternatively, the analysis form can be e-mailed and fee paid by credit card. If you require any further information about this process please e-mail or telephone us at 01475 724629. A full analytical report will be e-mailed or sent to you detailing recommended treatments.

Should you decide to proceed with the treatments you may order via e-mail or by post, including your cheque.

Professional Analysis and Treatments for Hair Loss, Scalp Disorders and Skin problems.

TRICHOLOGICAL ANALYSIS FORM

Male...............Female...............

Date Of Birth.................................................................

NAME.....................................................................................................................

Address.....................................................................

............................................... Post Code.......................................................

Telephone Number.....................................................................................

Email.....................................................................................

Ethnic group
Asian.....................Afro......................Caribbean...............................
Caucasian............ Oriental........................Other.......................................

Occupation..................................................................
.............................................

Sporting activities
(Specify)....................................................................
.........................

How often..........................................................................................................
Are you on any kind of diet?.....................................If so, what type?.................................

General diet
Quality:..................... Good................... Average................... Poor..................
Estimate daily liquid intake.......................................General Health.................................

Please detail any illnesses or surgery in the last 12 months
................................................................................................................................................................
Prescribed Medicines?..................................................................................................

Family Genetic History: Premature hair
loss...............any other genetic conditions.......................
ADDITIONAL INFORMATION AND COMMENTS: please give as much information as possible about your hair condition.........................................................................................................................................................

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Please answer as many of
the above questions as possible. If unsure please leave blank or contact us
for information.

PRESENT HAIR CARE
Products normally used........................................................................
.................................................................................................................................................................
Shampooing: How Often?......................................................................
Why?......................................................................................................................
...............................................................................................................................
When?
Morning.................................................Evening.............
Hair Structure:
Course.........................Average.............................Fine.....
Condition:
Tinted...............................Permed..............................Highlighted...................
Damage: Over
processed......................Chemical...........................SunDamage...................
Other......................................................................................................................Strength:
Strong................................. Normal........................... Limp............................
Density: Poor....................................Normal...........................Thick..........................

HAIR LOSS
When did it commence?...............................................................................................
Howsevere..............................................................................................................
Where?
All over (Diffuse)......................................
Front (temple).....................................
Crown (vertex)...................................................
In Patches..........................................

VISUAL AND MANUAL OBSERVATIONS SCALP
Scalp movement:
Yes..........................slight...................................No............................
Does the scalp move easily across the skull?
Quality of scalp:
Thin.........................Soft/spongy............................Thick... ......................
Colour of Scalp: White.............Yellow............Grey.............Pink.............Red......................
Scalp Irritation/Itchiness?..............................................................................................
Dandruff: Fine
Flakes..............Large...............Sticking to scalp............... Around hair line and ears....................................Large............................................................................
Incrustations............................. Psoriasis.............................. Eczema..............................
Greasiness: All over hair and scalp............Mostly greasy towards the end of the day...................
Mostly greasy in the morning...................Mostly greasy roots but dry ends.............................

Ninian Smith 46 Inverkip Street Greenock PA15 1YT Scotland UK Fax: 01475 729 255
E-mail: Ninian Smith
You may book a personal appointment for consultation and analysis.