2023 Hair Loss Assessment Form

Do You Suffer From Hair Loss?

Let's Gather A Few Details & Schedule Your Assessment Screening Appointment To Get You Started On Your Road To Recovering Your Healthy Hair.
What Is Your Name?*

First NameLast Name
Cell Phone Number*
Email*
example@example.com
What Is Your Birth Date?*

MonthDayYear
Type It In
How Did You Hear About Our Hair Loss Clinic?

Google SearchCustomer ReferralStylist RecommendationOur Website Advertisement
Current Address (This is only used for shipping products to you if required.)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What Is Your Current Height?
* feet
* inches.
What Is Your Current Weight?*
In lbs. (Approximate) - Ex: 165
What Is Your Blood Type Group? (The RH Factor (+/-) Is Not Required For This Question.*

A (+/-)B (+/-)O (+/-)AB (+/-)I Don't Know ItI would like a blood test done
My Hair Texture Is...*

NaturalRelaxedCurlySlight WaveStraight
What Areas of The Scalp Are You Experiencing Hair Loss?*

My EdgesMy Middle Part Part Area; Is Getting WiderMy Crown Area; On The Top of My Head Is ThinningBoth; My Front Hairline & Crown Are ThinningMy Hair Is SheddingMy Hair Is Growing Out, But It Looks ThinnerMy Hair Is No Longer GrowingI Have Excessive Shedding
How Long Has This Been An Issue For You?*
Do You Have A Family History of Hair Loss? (men, women, aunts, uncles, grandparents, siblings)?*

YesNo
Do You Have A Burning or Itchy Sensation On Your Scalp?*

YesNo
Do You Have Any Symptoms of Constipation, Acid Re-Flux, or IBS?*

YesNo
Have You Recently Had A Baby or A Surgical Procedure?*

YesNo
Are You Currently Pregnant or Breastfeeding?

YesNo
Do You Currently Take Any Prescribed Medications For Any of The Following?

High Blood PressureDiabetesThyroidGastro Issues / IBS / ConstipationBirth ControlMenopause / Hormone Replacement Therapy
Are You Experiencing Any of the Following "Scalp Conditions"?*

EczemaPsoriasisSeborrhea DermatitisDandruffNo Current Scalp Conditions
Have You Seen A Dermatologist For A Scalp or Hair Loss Condition?*

Scalp Condition - YesScalp Condition - NoThe Scalp Condition Treatment Was Not SuccessfulHair Loss Treatment - YesHair Loss Treatment - NoThe Hair Loss Treatment Was Not Successful
Where You Diagnosed With A Type of Hair Loss By A Dermetologist or Doctor?
Have You Tried Other Programs / Products In The Past?*

Hair Growth Oils/ Creams / GelsHair Growth VitaminsHair Growth ShampoosInjectionsLLLT - Low Level Laser TherapyPRP - Platelet Rich PlasmaRogain - RX or OTC
According To The Scale Above; Which Hair Loss Pattern Do You Have?

Level 1Level 2Level 3Level 4Level 5Level 6Level 7Level 8
Take A Photo of - Your Front Hairline
Take A Photo of - The Top of Your Head
Take A Photo of - An Additional Area of Concern
Thank You For Completing Your Online Assessment Today!

The Next Thing To Do Is...

Schedule Your Assessment Screening Appointment

As Soon As Possible - On Our Website 24/7 @

www.uniquecreationshairstudiosllc.com

1. Go to the Book Now Button

2. Select Our Salon

3. Go To : The Hair Loss Services - Menu

4. Select Step 2 & Book Your Screening Appointment

Please Submit Your Form Now & A Copy Will Come To Your Email Provided.
Should be Empty:

Do You Suffer From Hair Loss?