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Hair Loss
1
How Stealth Health Works
A short message from our CMO
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2
Email
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3
Medication
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4
Dosage Instructions
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5
Quantity
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6
Repeats
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7
Please enter a promo code if you have one (Optional)
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8
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
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9
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
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10
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
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11
Have you been exposed to:
Chemotherapy
Radiation
Heavy Metals
Colchicine
Cyclosporine
None
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12
How have you experienced hair loss or thinning?
Gradual
Sudden
Patchy
Overall thinning
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13
What is your natural hair type?
Oily
Dry
Balanced/Normal
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14
Please describe your hair type:
Fine
Course
Thick
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15
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
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16
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
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17
Is there a history of hair loss in your family?
YES
NO
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18
Please take a photo of the affected area
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Select files to upload
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19
Have you been diagnosed with hormonal imbalance?
YES
NO
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20
Do you have a history of high heart rate, cardiovascular disease or decreased blood pressure?
YES
NO
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21
How frequently do you experience stress?
Constantly
Occasionally
Seldom
Unsure
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22
Have you ever received treatment for hair loss including any medical procedures, medications, vitamins, or supplements for this purpose?
YES
NO
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23
If yes, please explain:
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24
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
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25
How much exercise do you get per week?
None
1 hour or less
1-3 hours
3 hours or more
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26
How often do you consume alcohol?
Rarely/Never
Sometimes
Frequently
Daily/Always
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27
Have you used any of the following substances in the past six months?
Cocaine
Methamphetamine
Opioids
Cannabis
None
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28
Do you smoke?
YES
NO
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29
How often do you smoke? (Packs a week, etc.)
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30
Are you using any nicotine replacement products?
YES
NO
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31
Please explain:
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32
Do you have any concerns about potential side effects of hair loss treatments?
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33
Is there anything else you would like to share with the healthcare team?
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34
Full Name
*
This field is required.
First Name
Last Name
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35
Phone Number
*
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36
Date of Birth
Year, Month, Day
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37
Biological Sex
Male
Female
Intersex
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38
Are you currently pregnant or breast feeding?
YES
NO
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39
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
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The Gambia
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Gibraltar
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Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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40
Allergies?
YES
NO
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41
What is your allergy?
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42
Are you currently taking any medications, vitamins, herbs, or supplements?
YES
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43
Please list your medications, vitamins, herbs, and supplements here:
(Name, Strength, Regimen)
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44
Do you have any medical conditions?
YES
NO
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45
Please list your medical conditions here:
(Name, How long you've had the condition)
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46
Signature
By signing below you accept that the above information provided is accurate and truthful. You also acknowledge that a staff member will contact you for ID verification prior to dispensing the prescription.
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