Person to Contact in Case of an Emergency *
How did you hear about us?
What is the problem you are experiencing? *
Where are you experiencing hair loss? *
How old were you when you first noticed hair loss?
Is the hair loss sudden with smooth, round bald patches appearing in less than three months?
How long have you suffered from hair loss or thinning? *
Hair Loss-Approximately how much hair is left on your head? *
Have you experienced total hair loss on your face?
Have you experienced total hair loss on your body?
Is there a history of hair loss in your family? If so, which family member(s)? *
If you answered “other,” please explain
Do you exercise regularly?
Are you under constant pressure or stress?
How do you relax/relieve stress? *
Do you use hair extensions or weave?
Do you wear wigs or lace front regularly?
Have you plaited or braided your hair in the past five years?
Have you used bonding glue for your extensions?
Do you use clip-on extensions?
Do you wear ponytails regularly?
Do you have the following conditions? *
How often do you shampoo your hair?*
Do you use chemicals on your hair, like bleach, perm solutions, hair colorings, and relaxers?
Is there a crust buildup on your scalp?
Please describe any other skin problems on your body or face: *
Have you had a blood test in the last 12 months?
Do you ever use sharp objects to scratch your while wearing braids or weaves?*
Cite other conditions or expand on previous answers
Do you take prescription medicines? *
If yes, please list all medications (prescriptions/ non-prescriptions)
Do you have an iron deficiency or any other form of dietary deficiency?
Do you have an allergy to caffeine? *
Do you have any other allergies?
Are you allergic to latex?
Does your skin heal normally?
Are you presently under a doctor's care?
Have you used any medication or treatment in the past for hair loss or scalp conditions? *
What treatments for your hair loss have you used? *
Were you using any other hair loss treatments at the same time?
Have you received any treatment advice recently? If so, by whom? *
If yes, what advice did you get?*
What form of contraception do you use, if any? *
Have you recently given birth?
Have you or anyone in your immediate family suffered from breast cancer?
Are you currently pregnant?
Will you be trying for a child in the next 12 months?
Have you had a raised temperature/fever due to illness in the last 3-6 months?
Dietary Habits- What type of diet do you have? *
Do you take any mineral or vitamin supplements?
Has your weight changed dramatically in the last 12 months? *
Have you had any form of Gastro bypass, lap band, sleeve, etc.?
If you have any extra comments about your hair loss or scalp problem, please inform us:
Please check the box before submitting the form.