bear and scalp form | Bels Beauty Complex

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Bels Beauty Complex

First name

Last name

Email

Phone

Address

Birthday

Day

Month

Year

Sex

Male

Female

prefer Prefer not to say

What are your main concerns regarding your beard, scalp, or hair?What are your main concerns regarding your beard, scalp, or hair?

Dandruff

Redness of the scalp

Burning sensation

Bumps on the scalp

Itching

When did you first notice this concern?

Are there specific areas affected?

Crown

Hairline

Beard side

Chin

Other

Indicate

Do you apply anything on your scalp ?

yes

no

Give examples? Oils, ointment, creams, butter

When did you start applying it? Date

How often?

Was it prescribed by your GP or pharmacist??

Do you have any known medical conditions?

Yes

No

If Yes , Indicate

Are you currently taking any medications or supplements?

Yes

No

If Yes, kindly indicate

Does anyone in your family have a history of hair loss, alopecia, beard patchiness, or scalp conditions?

Yes

No

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31 Down Way, Northolt UB5 6PG, United Kingdom

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