couple

Evaluation

* Required Fields

Name: *
Address: *
City: *
State: *
Zip: *
Email: *
Phone: *
1. How long have you been losing your hair?
1-3 years 3-7 years 7-15 years more than 15 years

2. Where has the hair loss occured?
(A) (B) (C) (D) (E)

3. Is the scalp visible in the area where you have lost your hair?
Yes No
4. Do you suffer from...? (choose as many as applicable):
Dandruff Itchy Scalp Dry Scalp Oily Scalp
5. Would you characterize your existing hair as... (choose one)
 Dry Oily Normal
6. Is the hair growing on the sides of your head? (choose one):
thin and full thick and full thin and slightly receding
7. Does your scalp excrete excessive sebum (oils)?
 Yes No
8. Have you ever experienced a build-up of sebum (oil) on your scalp?
 Yes No
9. Does your scalp ever flake?:
Yes No
10. Do you ever see red blotches on your scalp?
 Yes No
11. How would you rate your current rate of hair loss? (choose one)
 Light Moderate Heavy
12. Have you experienced an increase in your rate of hair loss in the past year?
 Yes No
13. Have you ever tried to do anything about your hairloss?
 Rogaine Hair Transplant Hair Replacement Lotions/Shampoos
14. Have you ever seen a doctor about your hair loss?
 Yes No
15. Has anyone ever mentioned your hair loss to you?
 Wife Girlfriend Husband Boyfriend Mother Father Other
16. Does that bother you?
 Yes No
17. Do you want to:
Stop hair loss Have more hair

 
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