Мultielement hair analysis
Dаte of sampling<
>____________ 20_ y.
Surname
________________________________________________________
Name________________________
Patronymic____________________________
Weight____ kg Height
_____ сm
date of birth
« » ______________19 y.
blood group
__________________________
telephone______________________________________________
place of birth (city)_______________________________________________
Habitation
last 5 years _____________________________________
occupational hazard__________________________________________________
nourishment
:
mixed,
vegetarian
alcohol consumption
:
no,
moderate,
frequent
smoking: ______ years, ________ cigarettes a day
complaints
(diagnosis) ________________________________________________
_________________________________________________________________
Natural colour of hair__________________________________________
Dyeing, chemical hair wave
(what means, when) _____________________________
________________________________________________________________________________________
Usage of therapeutic agent s for hair
(what kind of therapeutic agents, when)___________________
___________________________________________________________________________
Taking of mineral complexes, medical products
(For last 3 months)______________________________________________________
*All gaps of the questionnaire have to be filled,
even in case of negative answer.