Tele Trichology Online Consultation - Hair related problems Please fill the below form, provide detailed information on existing medical condition, past medical history, current/past medications and attach available scan reports and pictures preferably high quality images as it would help our physicians to examine your ailment(s) with more clarity. (Step 1 of 4) Basic Information Full Name Age Sex Select Male Female Relationship Select Single Married Patient Type New Patient Existing Patient MR No (If any) Address* City Country Select Aruba Afghanistan Angola Anguilla Åland Islands Albania Andorra Netherlands Antilles United Arab Emirates Argentina Armenia American Samoa Antarctica French Southern Territories Antigua and Barbuda Australia Austria Azerbaijan Burundi Belgium Benin Burkina Faso Bangladesh Bulgaria Bahrain Bahamas Bosnia and Herzegovina Saint Barthélemy Belarus Belize Bermuda Bolivia Brazil Barbados Brunei Darussalam Bhutan Bouvet Island Botswana Central African Republic Canada Cocos (Keeling) Islands Switzerland Chile China Côte d`Ivoire Cameroon Congo, the Democratic Republic of the Congo Cook Islands Colombia Comoros Cape Verde Costa Rica Cuba Christmas Island Cayman Islands Cyprus Czech Republic Germany Djibouti Dominica Denmark Dominican Republic Algeria Ecuador Egypt Eritrea Western Sahara Spain Estonia Ethiopia Finland Fiji Falkland Islands (Malvinas) Federated States of Micronesia France Faroe Islands Micronesia, Federated States of Gabon United Kingdom Georgia Guernsey Ghana N Guinea Gibraltar Guadeloupe Gambia Guinea-Bissau Equatorial Guinea Greece Grenada Greenland Guatemala French Guiana Guam Guyana Hong Kong Heard Island and McDonald Islands Honduras Croatia Haiti Hungary Indonesia Isle of Man India British Indian Ocean Territory Ireland Iran, Islamic Republic of Iraq Iceland Israel Italy Jamaica Jersey Jordan Japan Kazakhstan Kenya Kyrgyzstan Cambodia Kiribati Saint Kitts and Nevis Korea, Republic of Kuwait Lao People`s Democratic Republic Lebanon Liberia Libyan Arab Jamahiriya Saint Lucia Liechtenstein Sri Lanka Lesotho Lithuania Luxembourg Latvia Macao Saint Martin (French part) Morocco Monaco Moldova Madagascar Maldives Mexico Marshall Islands Macedonia, the former Yugoslav Republic of Mali Malta Myanmar Montenegro Mongolia Northern Mariana Islands Mozambique Mauritania Montserrat Martinique Mauritius Malawi Malaysia Mayotte Namibia New Caledonia Niger Norfolk Island Nigeria Nicaragua R Norway Niue Netherlands Nepal Nauru New Zealand Oman Pakistan Panama Pitcairn Peru Philippines Palau Papua New Guinea Poland Puerto Rico Korea, Democratic People`s Republic of Portugal Paraguay Palestinian Territory, Occupied French Polynesia Qatar Réunion Romania Russian Federation Rwanda Saudi Arabia North Sudan South Sudan Senegal Singapore South Georgia and the South Sandwich Islands Saint Helena Svalbard and Jan Mayen Solomon Islands Sierra Leone El Salvador San Marino Somalia Saint Pierre and Miquelon Serbia Sao Tome and Principe Suriname Slovakia Slovenia Sweden Swaziland Seychelles Syrian Arab Republic Turks and Caicos Islands Chad Togo Thailand Tajikistan Tokelau Turkmenistan Timor-Leste Tonga Trinidad and Tobago Tunisia Turkey Tuvalu Taiwan, Province of China Tanzania, United Republic of Uganda Ukraine United States Minor Outlying Islands Uruguay United States Uzbekistan Holy See (Vatican City State) Saint Vincent and the Grenadines Venezuela Virgin Islands, British Virgin Islands, U.S. Viet Nam Vanuatu Wallis and Futuna Samoa Yemen South Africa Zambia Zimbabwe Contact Email Contact Number Appointment for Specialist Select Dr. Sooriya Sekar Dr. Sugandhan S Dr. Sooriya Sekar MD, DNB, FRGUHS (Dermatosurgery) Dermatologist Tamilnadu Medical Council No: 111658 Dr. Sugandhan S MBBS, D.D, MD (Derm), Fellow (Clin Derm) HOD - Dermatology Tamilnadu Medical Council No: 67413 Consultation fee Preferred Appointment Date* How did you know about MIOT Telemedicine?* Doctor Referral Facebook Internet MIOT SMS MIOT Website Online Advertisements Word of mouth Others (Please specify) Plesase Specify* (Step 2 of 4) Let us know about your hair problems and duration of the condition Problem One Duration Problem Two Duration + Do you have patchy hair loss? Yes (Specify) No Not Sure How much hair is lost approximately per day? Do you have dandruff? Yes No Do you have hair breakage / split ends? Yes No Any Significant illness in the Past one Year Yes (Specify) No (Step 3 of 4) Tell us know more about your general health and wellness Do you have anaemia (Low Haemoglobin)? Yes No Not Sure Do you have a Thyroid Disorder? Yes No Not Sure Have you lost significant weight in the past one year? Yes (Specify) No How many hours of sleep do you get? Do you work night shifts? Yes No Co Existing Medical / Surgical Conditions None Diabetes Hypertension Cardiac (Specify) Kidney Problem (Specify) Liver Problem (Specify) Nervous Problem (Specify) Others Cardiac (Specify) Kidney Problem (Specify) Liver Problem (Specify) Nervous Problem (Specify) Others (Specify) Current medications / Previous treatment details Yes (Specify) No Drug Allergy Select No Yes (Specify) (Step 4 of 4) Send your images and relevant documents Please provide high quality pictures as it would help our physicians to examine your ailment(s) with more clarity. Attach pictures of skin lesions (Please upload maximum of 1MB files only, all inclusive.) Add More Remove Attach previous / current prescriptions (Please upload maximum of 1MB files only, all inclusive.) Add More Remove Attach lab reports (if any) (Please upload maximum of 1MB files only, all inclusive.) Add More Remove Profile picture (optional) (Please upload maximum of 1MB files only, all inclusive.) 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