Alma TED screening questionnaire
Name
First Name
Last Name
Email
example@example.com
Cellphone Number
Please enter a valid phone number.
What is your gender?
Male
Female
Non-binary
What is your age?
What hair issue are you experiencing?
hair thinning
hair shedding
hair loss
How long have you had these issues with your hair
less than 1 year
1-2 years
3-5 years
6-10 years
more than 10 years
Have you been given a hair or scalp diagnosis?
yes
no
Which diagnosis?
Do any of these apply to you?
cochlear (ear) implant
Implanted deep brain stimulation device
metal plate in your head
pacemaker
currently pregnant
head or neck shunt
current or history of cancer or precancerous lesions on the scalp
eczema, psoriasis or other active rash/dermatitis on the scalp
Do you have clearance from your cardiologist for Alma TED treatments?
yes
No
Are you pregnant?
Yes
No
Submit
Should be Empty: