First Name
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Last Name
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Email
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Phone
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Gender
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Male
Female
Other
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Your Age
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Ethnicity
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Asian / East Asian
Black / African
Latino / Hispanic / Mediterianea
White / Caucasian
Other
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Financing - If you decide to move forward with one of our hair loss treatment, how would you like to pay for it? *
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Hair Loss Clinic Financing
Credit Card
Debit / e-Transfer
Cash
Other
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Where Is Your Loss?
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Scalp
Whole Head
Whole Body
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How Long?
*
What Are You Currently Doing For Your Condition?
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Did You Get Any Success With The Treatment, If Yes, How?
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Pattern Of Hair Loss
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Male Pattern Hair Loss (Horseshoe Pattern)
Female Pattern Hair Loss (Diffused)
Diffused (Other)
Patchy (Bald Spots)
Other Hair Loss
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Did You Receive Treatment or Advice From?
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None
Trichologist
Dermatologist
Family Doctor
Other
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How Long Have You Being Doing This?
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Is Your Scalp Hurt/ Tender/Inflamed?
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Yes
No
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Dandruff?
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Yes
No
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Is Your Scalp Itchy or Flaky?
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Yes
No
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Hair And Skin Condition?
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Oily Hair
Oily Skin
Oily Hair & Skin
Dry Hair
Dry Skin
Dry Hair & Skin
Other
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Immediate Family Members With Hair Loss Condition? If Yes, Who?
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Any Health Issue? If Yes, What Issues?
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Do You Have Thyroid, Anemia Issues?
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Thyroid
Anemia
None
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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?
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Are You Currently Dieting In The Past 6 Months, Any Dramatic Weight Changes?
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Your Weight?
Below
Normal
Slightly Obese
Obese
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Do You Take Any Vitamins, If Yes, What Type?
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Are You Taking Any Medication, If Yes, What Medication/s?
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Have You Changed or Stopped Taking Medication Recently? If Yes, What Medication/s?
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Any Hormonal Issues? If Yes, What Type?
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Pre Menopause / Menopause?
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Pre Menopause
Menopause
Neither
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Oral Contraceptives? If Yes, Since When? Have You Stopped Recently?
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Menstrual Cycle, Is It Regular, Irregular, Longer or Shorter?
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Are You Taking Any Hormone Replacement Therapy? If Yes, Any Issues?
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Any Stressful Even Before Hair Loss? If Yes, When?
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What Is Your Current Stress Level From 1-10, 10 Being Most Stressful?
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Do You Pull Your Hair? If Yes, Since When?
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Do You Over Process Your Hair? Use Hot Hair Dryer, Colour, Hair Straightener? Perm? Relaxers?
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Do You Tie Your Hair Pony Tail, Braiding, Extensions?
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How Often Do You Wash Your Hair?
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Using Your Cellphone, Please Take 3 Photos - Front, Top And Side Of Your Scalp
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Please Provide Any Additional Information About Your Hair And Scalp Condition That Is Useful For Our Assessment
*