Questionnaire: General (English)

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Full Name *

Phone Number *

MRN *

For the under eye area
*

I have puffiness under the eye

I have dark under eye

I don't have problems

Required

For hair
*

My hair is healthy

I suffer from falling

I suffer from voids

I suffer from baldness

I suffer from alopecia

I suffer from dandruff

Required

For your facial skin
*

My skin is clear

I suffer from acne

I suffer from scars and effects of acne

I suffer from enlarged pores

Required

For your skin tone
*

supple

It has redness

It has pigmentation and melasma

Non-uniformity of color

Faded and not fresh

Required

Do you show signs of aging quickly (wrinkles and sagging in the face) and do you look older than your age?
*

Yes

Do you suffer from fungus in the body or genital area?
*

Yes

Do you suffer from excessive hair growth or hirsutism?
*

Yes

Do you suffer from eczema or skin allergies?
*

Yes

Do you suffer from itchy skin?
*

Yes

For nails
*

My nails are healthy

I suffer from broken nails

I suffer from slow nail growth

I suffer from a change in the color of the nails

I suffer from a change in the shape of the nails

Required

Do you suffer from bruises, growths, or warts on the skin?
*

Yes

Do you suffer from excessive sweating?
*

Yes

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