Hair Loss Assessment (New)

1

What stage of hair loss do you currently have?* This field is required.

Pattern 2

Pattern 2A

Pattern 3

Pattern 3 Vertex

Pattern 3A

Pattern 4

Pattern 4A

Pattern 5

Pattern 6

Not Sure / Other

2

If you can't see your pattern of hair loss above, try to explain to us what's going on.

3

Was the hair loss sudden or gradual?* This field is required.

GradualSudden

4

Have you experienced hair loss on your face or body?* This field is required.

NoYes

5

Is there a history of hair loss in the family?* This field is required.

Yes

No

Not sure

6

Your answers indicate you may have signs of male pattern baldness. The good news is it can be successfully treated with a prescription treatment plan. Let's see if you're suitable for treatment?

Yes, Let's Fix It.

No Thanks, let my hair loss continue.

7

8

Name* This field is required.

First Name

9

Email* This field is required.

11

Are you male?* This field is required.

YesNo

12

When did you first notice you were losing your hair?* This field is required.

Less than 1 Year

Between 1 & 2 years

Between 2 & 5 years

5 years or more

13

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?

YesNo

14

Up to 6 months before your hair loss started have you:

Had any serious illness.

Been under a severe amount of stress such as a major operation or other traumatic event.

Started any nutritionally restrictive diets.

Your weight changed dramatically.

None of the above.

15

Please describe:

16

Do you suffer from any of the following:

Heart Conditions

Prostate Issues

Allergies

None of the above

17

Please describe:

18

Do you take any medications, either prescription or over-the-counter (including natural therapies)?* This field is required.

NoYes

19

Please list the medications or supplements you are taking.* This field is required.

20

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 not over 40

21

22

What treatments have you tried previously for hair loss?* This field is required.

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)

Dutasteride (either alone or in combination with minoxidil)

Other

23

What "other" treatments have you tried?

24

How long did you use (or have been using) the treatment for?* This field is required.

1-7 Months8 + Months

25

How did you use the treatment?* This field is required.

Whenever I could remember (less than 5 days a week)

Most days (5-6 days a week)

Everyday as directed

26

How effective was it?* This field is required.

Regrowth of new hair and stopped my hair loss

Stopped my hair loss

Slowed my hair loss

Didn't work at all

27

Do you find you're very sensitive to the side effects from medication you've taken in the past?* This field is required.

NoYes

28

Please describe in more detail about previous sensitivity to side effects.

29

Is your partner pregnant or trying to get pregnant in the next 12 months?* This field is required.

NoYes

30

If pregnant, how many months?

Less Than 4 months4 months or more

31

Have you ever received treatment advice regarding your hair loss?* This field is required.

YesNo

33

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? * This field is required.

SerumOral Capsule

34

Is there any other information you would like to share with the doctor or specific questions you'd like answered?

35

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.* This field is required.

Yes

37

Friend's Name

38

Which Barbershop?

39

What is your preferred method of communication?* This field is required.

EmailSMS

40

Mobile Number* This field is required.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 :)

41

Well done, you've completed the first step towards real change.