Sample hair loss questionnaire is a pool of hair related questions which helps to gather information regarding the condition of hair and the things which are really leading to hair loss. This sample hair loss questionnaire also helps the hair product manufacture companies to improve themselves and launch good and beneficial hair products based on the majority.




Fill your details:

Name: ________________
Gender: _______________
Age:    _________________
Area/ district you live: ______________


Sample Hair Loss Questionnaire 


Which type of hair you have?
A) Dry B) oily c) normal

Which brand shampoo you use?
A) Matrix B) sun silk c) tresemme d) dove e) any other _________

Do you have dandruff?
A) yes B) no c) some times

Do you have itchy scalp?
A) Yes B) no c) some times

How many times you have changed your shampoo?
Once B) twice c) thrice d) any other answer ________

How many shampoos you have used till date?
A) 1 B) 2 c) 3 d) any other answer ________

How often you prefer to shampoo your hair?
Once a week B) twice a week c) thrice a week d) any other answer _______

Mention all the shampoo names that you used? At least 3
____________
_____________
_____________


Will you apply oil on your scalp?
A) Yes B) no c) not always d) once a while

How often you prefer to apply oil on your scalp?
A) Once a week B) twice a week c) thrice a week d) any other answer ________

Which oil you use on your scalp? Name the oil?
almond oil
jojoba oil
olive oil
coconut
any other __________

How many hours before you apply oil before going to head bath?
1 hr.
One day before
12 hrs.

How often you do head bath?
A) Once a week B) twice a week c) thrice a week d) any other answer _______

Will you apply conditioner after your head bath?
A) Yes B) no c) sometimes

Which brand conditioner you use?
Matrix
Sun silk
c) Rusk
d) Dove
e) Any other _________

How you will dry up your wet hair?
A) Sun light B) hair dryer c) any other

Will you comb your wet hair?
A) Yes B) no c) sometimes

How many times a year you go for hair cut?
A) Twice B) thrice c) once d) no hair cut e) any other answer

What’s the volume of your hair?
Thin B) medium c) thick d) very thick e) any other answer

What’s the length of your hair
A) short B) very short c) above your knee d) below knee e) above shoulder line f) any other answer

Best shampoo according to you?
A) Tresemme B) matrix c) any other, name it __________

Best conditioner according to you?
Matrix
Sun silk
c) Rusk
d) Dove
e) Any other _________

Best oil according to you?
almond oil
jojoba oil
 olive oil
argan oil
walnut oil
amla seed oil
coconut oil
anyother

Which type of comb you use?
A) Handmade B) machine made

Will you share your comb with any one?
A) Yes B) no c) not always

What type of problem you have with your hair?
Dandruff B) hair loss c) itchy scalp d) any other please mention ____________

 How you’re losing your hair?
A) Over the scalp b) breakage of hair c) any other ________

 Are you taking any medicines?
A) Yes B) no C) if yes mention the list of medicines

What type of food you prefer to take? Mention your diet
_________________________

How many times a day you take your meal?
A) Once B) twice C) thrice d) any other answer _______________

How long you’re observing your hair loss?
One month B) 15days c) one week d) 6months e) one year d) any other answer _____