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First Name:

Last Name:

Address:

City:

State:

Zip Code:

Email:

Primary Phone:

Evening Phone:

Date of Birth:

Best time to
contact you:

1. How long have you been experiencing hair loss?

1-3 years

3-7 years

7-15 years

more than 15 years

2. Please select a hair loss pattern that may be similar to your own.

(A)

(B)

(C)

(D)

(E)

3. Have any members of your family experienced hair loss? Select all that apply

4. Would you say that within the past 6 months to a year that your hair loss has increased?

Yes

No

5. Have you seen a doctor about your hair loss?

Yes

No

6. Is the current condition of your hair:

Oily

Dry

Flaky

Normal

7. Have you ever had any of the following: Select all that apply

8. Have you ever used any of the following treatments for your hair loss? Select all that apply

9. Has anyone ever commented on your hair loss? Select all that apply

10. If someone does comment on your hair loss, what do you do?

Feel angry

Feel sad

Get defensive

Shrug it off

11. Why would you like to do something about your hair loss? Select all that apply

12. Would you like to: Select all that apply

Mother

Father

Brother

Sister

Uncle (mother's side)

Transplants

Scalp Reduction

Implants

None of the Above

Rogaine

Propecia

Nutriol

Niaxon

None of the Above

Spouse

Girlfriend

Boyfriend

Mother/Father

Coworker

Other

None of the Above

Hair loss makes me look older than I am.

I can't style my hair the way I used to.

I want to meet youngert men/women

More hair will make me feel better about myself.

Stop your hair loss

Have more hair