First Name *

Last Name *

Email *

Phone *

Gender *

Your Age *

Ethnicity *

Financing - If you decide to move forward with one of our hair loss treatment, how would you like to pay for it? * *

Where Is Your Loss? *

How Long? *

What Are You Currently Doing For Your Condition? *

Did You Get Any Success With The Treatment, If Yes, How? *

Pattern Of Hair Loss *

Did You Receive Treatment or Advice From? *

How Long Have You Being Doing This? *

Is Your Scalp Hurt/ Tender/Inflamed? *

Dandruff? *

Is Your Scalp Itchy or Flaky? *

Hair And Skin Condition? *

Immediate Family Members With Hair Loss Condition? If Yes, Who? *

Any Health Issue? If Yes, What Issues? *

Do You Have Thyroid, Anemia Issues? *

Any Recent Surgery? If Yes, What Type? *

Blood Work Past 6-9 Months? If Yes, What Result? *

Do You Eat Well? Meals Per Day? Eat Red Meat? Vegan? *

Are You Currently Dieting In The Past 6 Months, Any Dramatic Weight Changes? *

Your Weight?

Do You Take Any Vitamins, If Yes, What Type? *

Are You Taking Any Medication, If Yes, What Medication/s? *

Have You Changed or Stopped Taking Medication Recently? If Yes, What Medication/s? *

Any Hormonal Issues? If Yes, What Type? *

Pre Menopause / Menopause? *

Oral Contraceptives? If Yes, Since When? Have You Stopped Recently? *

Menstrual Cycle, Is It Regular, Irregular, Longer or Shorter? *

Are You Taking Any Hormone Replacement Therapy? If Yes, Any Issues? *

Any Stressful Even Before Hair Loss? If Yes, When? *

What Is Your Current Stress Level From 1-10, 10 Being Most Stressful? *

Do You Pull Your Hair? If Yes, Since When? *

Do You Over Process Your Hair? Use Hot Hair Dryer, Colour, Hair Straightener? Perm? Relaxers? *

Do You Tie Your Hair Pony Tail, Braiding, Extensions? *

How Often Do You Wash Your Hair? *

Using Your Cellphone, Please Take 3 Photos - Front, Top And Side Of Your Scalp *

Please Provide Any Additional Information About Your Hair And Scalp Condition That Is Useful For Our Assessment *