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Hair Loss Assessment
1
Name
*
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First Name
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2
Email
*
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3
Type of Client
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4
Lifecycle Stage
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5
What is your current age?
*
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Under 18 years
18-25 years
26-35 years
36-45 years
46 years plus
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6
Are you male?
*
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Yes
No
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7
What pattern/stage of hair loss do you have?
*
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Pattern 1
Pattern 2
Pattern 3
Pattern 3 Vertex
Pattern 4
Pattern 5
Pattern 6
Not Sure / Other
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8
If you can't see your pattern of hair loss above, try to explain to us what's going on.
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9
When did you first notice you were losing your hair?
*
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Less than 1 Year
Between 1 & 2 years
Between 2 & 5 years
5 years or more
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10
Harley treatments are effective at stopping further hair loss and regrowing hair lost in the last 2-3 years. Would that be an acceptable result for you?
Yes
No
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11
Was the hair loss sudden or gradual?
*
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Gradual
Sudden
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12
Have you experienced hair loss on your face or body?
*
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No
Yes
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13
Is there a history of hair loss in the family?
*
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Yes
No
Not sure
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14
Have you had any serious illness at any time before or during the hair loss?
*
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No
Yes
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15
Please provide more information on the illness.
*
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16
Have you been under a severe amount of stress such as a major operation or other traumatic event at any time just before or during the hair loss?
*
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No
Yes
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17
Please provide more information on the stressful event.
*
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18
Have you started any nutritionally restrictive diets at any time before or during the hair loss?
*
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No
Yes
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19
Please provide more information on the diet.
*
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20
Has your weight changed dramatically over the last 12 months?
*
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No
Yes
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21
Do you suffer from any heart conditions?
*
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No
Yes
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22
What heart condition/s do you suffer from?
*
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23
Have you or other family members ever suffered from prostate disease or other prostate problems?
*
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No
Yes
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24
Please describe the prostate issue
*
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25
Do you take any medications either prescription or over the counter (including natural therapies?
*
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No
Yes
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26
Please list the medications or supplements you are taking.
*
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27
Do you suffer from any allergies?
*
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No
Yes
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28
What allergies do you suffer from?
*
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29
If you're over the age of 40, have you had a thorough checkup with your GP in the last 12 months?
Yes
No
I'm mot over 40
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30
What treatments have you tried previously for hair loss?
*
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No other treatments
Minoxidil 5% (Regaine or generic equivalent)
Finasteride 1mg (Propecia, Proscar or other generic equivalent)
Combination treatment of Finasteride and mInoxidil (including other treatment programs such as Ashley & Martin, Advanced Hair Ect)
Other
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31
What "other" treatments have you tried?
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32
How long did you use (or have been using) the treatment for?
*
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1-7 Months
8 + Months
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33
How did you use the treatment?
*
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Whenever I could remember (less than 5 days a week)
Most days (5-6 days a week)
Everyday as directed
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34
How effective was it?
*
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Regrowth of new hair and stopped my hair loss
Stopped my hair loss
Slowed my hair loss
Didn't work at all
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35
Do you find you're very sensitive to the side effects from medication you've taken in the past?
*
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No
Yes
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36
Please describe in more detail about previous sensitivity to side effects.
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37
Is your partner pregnant or trying to get pregnant in the next 12 months?
*
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No
Yes
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38
If pregnant, how many months?
Less Than 4 months
4 months or more
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39
Have you ever received treatment advice regarding your hair loss?
*
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Yes
No
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40
Who did you receive advice from?
*
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GP
Dermatologist
Pharmacist
Barber/Hardresser
Other
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41
If you're suitable for a Harley treatment plan, there's an option of a once daily serum applied to the scalp or a capsule taken orally. What would be your preference?
*
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Serum
Oral Capsule
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42
Is there any other information you would like to share with the doctor or specific questions you'd like answered?
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43
I confirm I have answered the above questions honestly and to the best of my knowledge. I understand that the information, advice and treatment provided by Harley are based on these responses.
*
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Yes
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44
How did you hear about Harley?
*
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Google
Facebook
Instagram
Barber
Friend
Other
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45
Which Barbershop?
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46
What is your preferred method of communication?
*
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Email
SMS
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47
Mobile Number
*
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If your preferred method of communication is email, we'll send you an SMS to alert you to check your email inbox. This avoids treatment plans getting lost in your spam folder :)
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48
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