Hair Loss Questionnaire
Hair loss (Alopecia) can start at almost any age as you enter adulthood. You can start losing your hair as early as your late teens and early 20s. But you might have a full head of hair with almost no thinning or balding until well into your 50s and 60s.There’s a lot of variation from person to person. But the general consensus around balding is that the older you get, the more likely you’ll see signs of balding. This questionnaire will help us assess your current condition and help us create a treatment plan for you.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
How old are you?
What is your gender?
Male
Female
Have you ever been diagnosed with any conditions that cause hair loss(alopecia)? If so, what conditions?
Do you take any testosterone replacement therapy? (this includes doctor prescribed testosterone or non-prescription Anabolic steroids etc.)
Yes
No
Does anyone in your family already suffer from hair loss?
Yes, on my mother's side
Yes on my father's side
Yes, on both sides
No
Does any of the following describe you?
Tired all the time
Excess weight gain or weight loss
Vegan or Vegetarian Diet
None
Do you currently have dandruff or scalp itching?
Yes
No
both
Are you losing air in clumps or strands?
Clumps
Strands
Patches
Excessive Shedding
What shampoos and/or conditioners are you currently using?
How often are you washing your hair?
Once a week
2-3 times a week
Every Two weeks
Once a month
Other
How are you currently eating?
Healthy and balanced
Mostly fast or processed foods
High in carbs or sugar
High-protein or low-carb
Following a specific diet (e.g., keto, vegan, intermittent fasting)
If you are following a specific diet, what is that diet?
Keto / Low-Carb
Vegan
Pescatarian
Paleo
Other
No specific diet
Are you currently in a weight loss program?
Yes
No
If yes, which program?
What vitamins, if any, are you currently taking?
Are you currently takin any medications? If so, which medications?
Would you like to schedule a consultation with our expert team? The consultation fee is $85 and will be applied toward your treatment or product plan if you decide to complete the treatment.
Yes, I'd like to book
Not at this time
My Products
*
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Consultation Booking
This consultation is for clients interested in hair restoration, weight loss, injectables, or advanced skincare treatments. You'll meet with a licensed professional to discuss your goals and receive a personalized treatment plan.
$
85.00
Consultation type
In person
Virtual
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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