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History Form
Male Female
 Hair    Skin    Obesity  
Hair Oil
Hair Wash
Times/Week
Times/Week
approx,strands of hairs
days
after
days
Too Much
Area
white matter exfoliation after itching
months/years
gm%
date
times/day:sit for_mins
days/months
days/months
days
 Anger    Cry    Irriation  
  Depression    Beating    Slow Downs  
o'clock
  hr/day &
  hrs/night
 Y     N
Months/Year
Days
times/months
Self Limited/Medication=
Medications
Self Limited/Medication=
Medications
yrs of age
yrs of age
yrs of age
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