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Referred By - please select all that apply
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Local
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Radio
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Others, please specify
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Internet
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Other
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Referral - Name
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Hair Stylist - Name
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Please select the appropriate answer for the following questions
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What is your primary goal for this treatment?
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How many years has it been since your hair loss become noticeable to you?
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How has your hair been thinning?
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Has your hair loss been
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Currently, has your hair loss
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Do you have family history of Hair loss?
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If yes, What side of your family?
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Women Only
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Are you pregnant or breastfeeding?
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Are you now, or have you ever been on birth control?
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If yes when?
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Do you have a family history of cancer?
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If yes, Type of Cancer
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Are you post-menopausal?
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Have you had a hysterectomy?
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Please select the appropriate answer for the following questions
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At any time, have you used any of the following products to treat your hair loss?
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Others, please specify
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Have you had hair transplants or a scalp reduction?
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Do you have any of the following conditions on the scalp?
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How often do you wash your hair?
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Have you used any testosterone enhancing or hormone replacement substances within the last 2 years?
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If Yes, Explain
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What is your Blood Type?
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Do you currently have any medical conditions?
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Please list Medical Conditions below if you have answered yes
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Please also list any allergies whether environmental or food
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Please list ALL medications and nutritional supplements you take
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Which of the following does your diet consist most of?
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How often do you eat red meat?
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How many times a week do you exercise?
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FOR OFFICE USE ONLY
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