Clone of User Intake Form

1

What brings you here today?

Hair regrowth

Sexual preformance

Both

2

Have you sought treatment in the past?

Yes

No

3

What made you want to take action now?

What I've tried hasn't worked

I've noticed changes recently

All of the above

4

Do you have any of the following conditions?

High blood pressure

Low blood pressure

Depression/anxiety

Other

None of the above

5

Are you currently taking any medications?

6

How would you describe your current sexual performance or function

Consistent and satisfying

Occasionally difficult to maintain

Frequently difficult to maintain

Prefer not say

7

Have you noticed changes in your sexual desire or function?

Increase

Decrease

No change

8

Do you have any difficulty achieving or maintaining an erection sufficient for sexual activity?

Never

Sometimes

Often

Always

9

How long have you noticed this change or concern?

Less than 3 months

3-6 months

Over 6 months

10

What are you hoping to improve most?

Stronger erections

Increase sexual desire

Longer stamina

Improved confidence or mental focus

All of the above

11

How do you describe your current hair situation?

No major concerns

Mid thinning

Noticeable hair loss or receding hairline

Advanced or diffuse thinning

12

When did you first notice changes in your hair?

Less than 6 months ago

6-12 months ago

1-3 years ago

over 3 years ago

13

Where is the hair loss most noticeable?

Hairline / temples

Crown / top of scalp

Sides

Diffuse (overall thinning)

14

Your Name

First Name

Last Name

15

Your Email

example@example.com

16

Phone Number

Please enter a valid phone number.

17

Age

18

Gender

19

Signature

Clear

20

Please verify that you are human* This field is required.