Name and Last Name

Phone number

Please describe your hair loss issue *

1. Are you male or female?* *MaleFemale

2. How old are you? *Less than 2121 to 4545 to 5555+

3. How long have you been losing hair or thinning? *Less than 1 year2 to 5 years5 to 10 years10 +years

4. Does anyone else in your family suffer from hair loss or thinning hair? *YesNo

5. Do you have any medical conditions that require you to be under a doctors care? *YesNo

6. Have you had any weight loss or weight gains of 10 pounds or more in the past 12 months? *YesNo

7. How would you rate your stress levels? *AverageMore than AverageVery HighSevere

8. Have you suffered any life altering events that can be classified as “traumatic” in the past 5 years? *YesNo

Please indicate your preferred next step by selecting one of the following options: *I would like to be contacted a Hair Loss Specialist promptly to discuss my assessment / hair loss issue and potentially arrange a consultationI'm just curiuous about my hair loss; no further action is necessary

Best time to call *MorningAfternoomEvening

*Disclaimer: This is a general and preliminary assessment. An In-person Consultation and Scalp examination is necessary for a full treatment recommendation.

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