Valoris Lab

There are 3 sections to complete.

Time: 15-20 minutes. You can go back. Write in your own words. Answer honestly to allow us to find the best match with the right product.

Section 1

Name, first name or pseudonym:*

I am

Let’s speak about your hair

Even when clean, my head itches*

In which area of the head, are you losing/did you lose your hair*

On temples/in front On top On the back (crown) Close to ears At the nape of the neck Other

At least one option must be selected

Do/did you lose your hair in patches*

I am losing/ I lost my hair in big chunks*

At the same time, I am losing/ I have also lost all my eyebrows/ eyelashes*

I am losing / I have lost the hair of my beard/mustache*

I usually have dandruff/scabs on my head

Is there anything special about your hair (example: texture, color, smell, completely matted, strange regrowth, about pubic hair, etc, or nothing special)?

Hair loss sometimes occurs at specific times (changing job, stress, bereavement, illness, childbirth, accident, with medication, retirement, conflictual relationship, abortion, etc.). What events are linked to your hair loss?

Tell me the story of your hair loss*

Did you ever have*

Gonorrhea Tuberculosis Syphilis Do not know/ do not answer/ do not remember

At least one option must be selected

Do you have skin-related issues?*

Eczema Psoriasis Acne that is annoying you Warts Rosacea Urticaria Cold sore Aphthous ulcer (canker sore) Stye Skin tags Pus Other: give details

At least one option must be selected

Section 2

The health of your hair depends on your blood circulation, your immune system, etc. Here are several questions.

Is there a part(s) of your body that is very Hot all the time? (check all that apply)*

Hand Foot Nose Other zone Nowhere in particular Do not know/ hesitate

At least one option must be selected

Is there a part(s) of your body that is very Cold all the time? (check all that apply)*

Hand Foot and/or leg Face and/or nose Another location Nowhere in particular Do not know/ hesitate

At least one option must be selected

Are there any areas of your body that are regularly painful?

Generally speaking, I really CAN NOT stand (check all that apply)*

Heat Coldness / coolness Nothing special/ A bit of both/ I manage/ I do not like / i do not know

At least one option must be selected

Generally speaking, I feel really great (check all that apply)*

It depends With warm drinks In the sun With air conditioning With cold drinks/ Drinks with ice Without air conditioning In the shade Nothing special/ A bit of Everything/ I do not know/ I hesitate

At least one option must be selected

There is something special about me (check all that apply)*

I almost never SWEAT I sweat a lot in one place Nothing special about sweating I am HYPERsensitive to light I am hypersensitive to coldness I am hypersensitive to noise I am hypersensitive to smell I am hypersensitive to music I am sensitive, but not hypersensitive to the elements above I am always THIRSTY I am almost NEVER thirsty When I eat I lose the Taste of food I lost smell

At least one option must be selected

Anything you would have a hard time living without (example : a sport, food, etc. or nothing special): If you don't know, write Nothing special.

One thing you absolutely hate/loath/scare the hell out of you (or nothing special):

You are unique! Are there any sensations/reactions that characterize you?

(be specific, for instance : cold in a place, one area itches, feeling of having a grain of sand in the eyes, of having a helmet on the head, that a place burns, no color in the field of vision, your problem gets worse at night/in the morning/in the heat/in the cold, etc.). The more specific you are, the more you help us*

Think about your body, is there anything special?

(be specific even if it has nothing to do with your hair at first glance, for example: health problem, dizziness, burning hands, flatulence, gurgling, sciatica, headache, obese, anemia, mucus, constipation-diarrhea, incontinence, trembling where, sensitive gum, itchy scalp, particular pain, runny nose when you sneeze, bleeding gum, pain in a place, an obsessive compulsive disorder, your odor, varicose vein, constant cough, itchy place, excessive saliva, dry eyes, rhinitis, naturally shiny hair, no appetite, a food that you do not digest, etc.)

Section 3

Hair and nails are close relatives.

My natural nails are:*

Is there anything special about your nails (color, shape, feel, etc. or nothing special)?

You are: (Check all that apply)*

Very very thin
Slim
Fat
Big
Small
Tall
Normal
Do not know/Do not answer
Nothing special

Your personality matters! Stress can affect hair loss. Here are some questions.

Can you describe yourself in about 10 words, with your strengths and weaknesses*

Me and others...

In general, the company of other people:*

Me and anger:*

Me and my surroundings:*

Generally speaking, in a group I like to:*

By nature I am (check all that apply):*

Talkative Happy Timid HYPERsensitive Impatient Stubborn Hard to Satisfy Arrogant Depressed Jealous Sad Always Stressed Undecided Lacking Energy Anxious Wealth is Very Important Soft Lack Confidence Get Easily Angry Swinging Moods Meticulous Irritable Melancholic Egoist Indifferent to Anything Lazy Disorganized Others

At least one option must be selected

Do you have a health problem or illness identified by the medical system? (in general, even if it does not seem to be related to hairloss)

If there is anything else you think would be helpful and that was not asked, please let us know:

Age

Your Contact: Email, Phone or better both

We use this data to get in touch with you. We do not share it with anyone nor use it for advertising

Email*

Country Code*

Phone*

End. Thank you. If you want to provide comments to improve this questionnaire you are welcome. We will come back to you within 2-3 weeks with the best match.

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Hair Analysis Questionnaire

Valoris Lab

Section 1

Let’s speak about your hair

Section 2

Section 3

Your personality matters! Stress can affect hair loss. Here are some questions.

Me and others...

Your Contact: Email, Phone or better both

Country/region

Language

Hair Analysis Questionnaire

Valoris Lab

Section 1

Let’s speak about your hair

Section 2

Section 3

Your personality matters! Stress can affect hair loss. Here are some questions.

Me and others...

Your Contact: Email, Phone or better both