Hair Loss

1
Please enter a promo code if you have one (Optional)
2
When did you first notice your hair loss?
Seeking to prevent hair loss
Within the last month
In the last 2 to 5 months
In the last 6 months to a year
Over a year ago
3
Where did you first notice hair loss?
Receding hairline
Getting bald spot on the crown of the head
Both hairline receding and bald spot on the crown
Patchy with some odd hair loss all over scalp
4
Do any of the following apply to you within the past 2 months?
Pregnancy/Childbirth
Serious Illness
Major surgery
Endocrine disorders
Crash dieting
Severe anxiety/stress
None
5
Have you been exposed to:
Chemotherapy
Radiation
Heavy Metals
Colchicine
Cyclosporine
None
6
How have you experienced hair loss or thinning?
Gradual
Sudden
Patchy
Overall thinning
7
What is your natural hair type?
Oily
Dry
Balanced/Normal
8
Please describe your hair type:
Fine
Course
Thick
9
With treatment, what are your goals?
A stronger, defined hairline
Visibly thicker, fuller hair
More scalp coverage
Keep the hair I have
All of the above
10
Have you experienced any of the following?
Dandruff
Sudden increase in hair loss
Losing body hair
Pain, itching, burning, or bumps on scalp
Red rings or other rashes on the scalp
Hair loss other than on the head
Diagnosis of scalp psoriasis or scalp
Eczema
None
11
Is there a history of hair loss in your family?
YESNO
12
Please take a photo of the affected area
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13
Have you been diagnosed with hormonal imbalance?
YESNO
14
Do you have a history of high heart rate, cardiovascular disease or decreased blood pressure?
YESNO
15
Have you ever received treatment for hair loss including any medical procedures, medications, vitamins, or supplements for this purpose?
YESNO
16
If yes, please explain:
17
Have you experienced any of the following conditions, events, or symptoms?
Kidney Disease
Liver disease
Thyroid disease
Prostate enlargement
Cancer
HIV/Immune disease
Difficult and recurrent yeast/fungal infections
Rheumatological disorders or autoimmune diseases (Lupus, discoid lupus, sarcoidosis, psoriatic arthritis etc. )
None
18
Do you have any concerns about potential side effects of hair loss treatments?
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Ok
19
Is there anything else you would like to share with the healthcare team?
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20
Allergies?
YESNO
21
What is your allergy?
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22
Are you currently taking any medications, vitamins, herbs, or supplements?
YESNO
23
Please list your medications, vitamins, herbs, and supplements here:(Name, Strength, Regimen)
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Ok
24
Do you have any medical conditions?
YESNO
25
Please list your medical conditions here:(Name, How long you've had the condition)
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Ok
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Terms and Conditions* This field is required.
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