Hair Loss Questionnaire

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 NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How old are you?
What is your gender?

MaleFemale
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.)

YesNo
Does anyone in your family already suffer from hair loss?

Yes, on my mother's sideYes on my father's sideYes, on both sidesNo
Does any of the following describe you?

Tired all the timeExcess weight gain or weight lossVegan or Vegetarian DietNone
Do you currently have dandruff or scalp itching?

YesNoboth
Are you losing air in clumps or strands?

ClumpsStrandsPatchesExcessive Shedding
What shampoos and/or conditioners are you currently using?
How often are you washing your hair?

Once a week2-3 times a weekEvery Two weeksOnce a monthOther
How are you currently eating?

Healthy and balancedMostly fast or processed foodsHigh in carbs or sugarHigh-protein or low-carbFollowing a specific diet (e.g., keto, vegan, intermittent fasting)
If you are following a specific diet, what is that diet?

Keto / Low-CarbVeganPescatarianPaleoOtherNo specific diet
Are you currently in a weight loss program?

YesNo
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 bookNot at this time

My Products*

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.

$125.00 Consultation type

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Total

$0.00

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