Complimentary Hair Loss Quiz

1
Which image best matches your hair loss?* This field is required.
Temples
Temples & Crown
Modern
Extensive
Patchy
Complete
2
When did you start noticing your hair loss?* This field is required.
Less than 1 year ago
1-5 years ago
More than 5 years ago
I'm Not Sure
3
What is your hair type?
Straight or Wavy
Curly
Coily
Textured or Proceessed
A Combination
I Don't Have Hair
4
What is your ethnicity?
White
Asian
Mixed or Multiple ethnic group
Black
Other ethnic group
Prefer not to say
5
With treatment which results were you hoping for?Lifestyle
Regrow my hair
Prevent Further Hair Loss
Regrowth and Prevention
6
Does hair loss run in your family?Lifestyle
YESNO
7
How old are you?Health
Teens
20's
30's
40's
50's
60+
8
Do you suffer from any of the following scalp issues?Health
Sudden soreness/redness
Psoriasis
Dandruff
Sunburn
None, of these apply to me
9
How often do you feel stressed?Lifestyle
All the time
Sometime
Rarely
Not Sure
10
Do any of the following apply to you?Health
None, of these apply to me
I am undergoing PSA (prostate) monitoring or I have previously been diagnosed with prostate cancer
I am currently experiencing or have experienced depression, anxiety or panic attacks
Chronic Kidney Disease
Heart Attack/Stroke/ Mini-Stroke within the 6 months
Chest Pain Symptoms/ Heart rthythm Issues
Heart Value Problems
Phaeochromocytoma
Breathlessness / chest pain via exertion i.e 20 min walk / climbing stairs
11
Are you allergic to any of the following?Your Health
No, I Am Not Allegric
Minoxidil
Finasteride
Dutasteride
Lactose
12
Have you tried any of the following treatments?
Minoxidil or Regaine
Finasteride or Propecia
No, I’ve not tried any of these
13
Which are important to you?(Select all that apply)
Maximizing my results
Minimizing side effect risks
Better Hair texture
Novel treatments
Less greasy treaments
None of the above
14
Are you considering a hair transplant to enhance your medication results?
Yes, I am considering a hair transplant
No, I want to use only medication
15
Would you like to share your health information with your GP?To get the best results from your treatment plan and improve results we encourage you to consent to us sharing your treatment plan with your GP.
Yes
No
16
Lastly, do you agree and consent to the following?I am male, between 18 and 65 years old and live in the US. I will be the sole user of any medication offered to me through this service. All answers are provided by me and will be completely truthful I confirm that I am experiencing male pattern baldness (androgenetic alopecia) I am aware that minoxidil 10% spray, minoxidil spray with topical finasteride, and oral minoxidil are prescribed as unlicensed products I agree to inform the service of any changes to my medical history to ensure clinicians are informed and, if necessary, re-assess my suitability for treatment.
YESNO
17
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