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Ayurvedic Hair Health Assessment
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1
About You
2
Hair Health
3
Internal Health
4
Scalp Assessment
Ayurvedic Hair Health Assessment
Complete this assessment to receive personalized Ayurvedic recommendations
About You
Full Name*
Email Address*
Phone Number*
Date of Birth*
Height (Feet)*
Height (Inches)*
Weight (kg/lbs)*
Gender*
Male
Female
Other
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Hair Health
Tell us about your current place:*
Coastal (humid areas)
Plain (central region)
Mountains
Urban/Industrial (pollution exposure)
What kind of weather are you expecting over the next 60 days?*
Cold and Dry
Mild and Pleasant
Rainy and Humid
Hot and Dry
Select your Hair Type:*
Straight
Wavy
Coil
Curly
Combination (e.g. wavy + curly)
Preferred water temperature for hair wash:*
Cold
Lukewarm
Hot
What type of water do you use for hair wash?*
Hard
Soft
I Don't Know
How frequently do you use shampoo/conditioner?*
Daily
3+ times/week
1-2 times/week
1-2 times/month
Never
How frequently do you dye/colour your hair?*
Monthly
Every 2–3 months
Every 6+ months
Never
How often do you use heat-styling tools?*
Daily
Occasionally / Rarely
Never
How many times do you oil your hair in a week?*
Never
1 time/week
2–3 times/week
4+ times/week
How was your natural hair quality during your school/college years (before current concerns)?* (Select all that apply)
Soft / Silky
Dry
Oily / Sticky
Straight
Curly
Dense
Rough
Do you have a family history of early baldness?*
Paternal
Maternal
Both sides
Siblings
None
Does someone who stays with you experience similar hair problems?*
Yes
No
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Internal Health
Do you have any of these health conditions? (Select all that apply)
Diabetes
High BP / High Cholesterol
Thyroid
PCOD / PCOS
Hormonal Imbalance / Menopause
Anemia / Vitamin Deficiency
IBS / Digestive Disorder
Psoriasis / Scalp Skin Condition
Chronic Stress / Anxiety
None
Have you experienced any of these in the last 3 months?*
Malaria
Dengue
Typhoid
Severe illness with high fever (Flu, Jaundice, Covid, etc.)
None
What type of hair medication are you currently using?*
Internal
External
None
How stressed are you?*
High (very frequent stress)
Moderate (sometimes)
Low (rarely stressed)
None
How do you rate your sleep quality?*
Poor (disturbed / wake up often)
Average (okay but not restful)
Good (mostly restful)
Excellent (deep & sound)
How do you rate your appetite or eating capacity?*
Poor (low appetite)
Inconsistent (changes often)
Moderate (normal appetite)
Excellent (strong appetite)
How is your bowel movement?*
Constipated
Normal
Loose / Frequent
Which taste do you like the most?*
Spicy
Sweet
Salty
Sour
Bitter
How often do you consume non-veg food (excluding eggs)?*
Never (Vegetarian)
1–3 times/month
1–3 times/week
4+ times/week
How often do you eat food cooked outside?*
Rarely (mostly home-cooked)
1–2 times/month
2–4 times/week
5+ times/week
What does your daily work primarily entail?*
Mostly sitting
Mostly standing
Traveling frequently
Mixed / Other
What do you regularly use for commuting?*
Car
Public Transport
Two-Wheeler
Walk / Cycle / None
Which of the following do you consume frequently? (Select all that apply)
Smoking
Alcohol
Tobacco
Cold Drinks
Tea / Coffee
Packaged Snacks / Junk Food
None
How often do you sleep late at night?*
5+ nights/week
2–4 nights/week
1–2 nights/month
Rarely
In the last 2 months, what is true about your weight?*
Gained
Lost
Same
How often do you work out/play sports/exercise?*
Daily (6–7 days/week)
Often (4–5 days/week)
Sometimes (2–3 days/week)
Rarely (0–1 days/week)
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Scalp Assessment
Your scalp naturally tends to be:*
Very Dry
Dry
Normal
Oily
Very Oily
The top 3 concerns that you are facing presently (Select any 3):
Hair Fall
Hair Breakage & Split Ends
Dandruff / Flakes
Premature Greying
Poor Growth / Thin Hair
Itchy Scalp
Frizzy Hair
Burning Sensation
Blisters
Select the severity of your problems:
Itchy scalp:
Mild
Moderate
Severe
None
Burning sensation on the scalp:
Mild
Moderate
Severe
None
Blisters on the scalp:
Mild
Moderate
Severe
None
How did your problem start?
Itchy scalp:
Suddenly
Gradually
Never
Burning sensation on the scalp:
Suddenly
Gradually
Never
Blisters on the scalp:
Suddenly
Gradually
Never
If you don't apply anything to your hair, your hair tends to be:*
Rough
Sticky
Thin
None
Do you experience bad odor from your hair/scalp?*
Always
Sometimes
Never
Do you have skin problems similar to those on your scalp (itching/scaling)?*
Yes
No
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