Here an alternative version of our assessment if you are having trouble with the multi-step form. Thank you for your patience while we resolve this. Please select your gender first:* MaleFemale This is to make sure we ask the right questions. Contact info Date* First Name* Last Name* Email Address* Confirm Email Address* Address* City* State* Zip Date of Birth Age Medical History Describe your overall general health: * —Please choose an option—Excellent HealthGood HealthPoor Health Has your doctor ever indicated you may have nutrient malabsorption? Malabsorption definition: Difficulty in the digestion or absorption of nutrients from food. YesNoUnknown Have you had any surgery within the last year with General Anesthesia? * YesNo Do you have any of the following medical problems? Irregular Heartbeat * YesNo Do you take medication to control this condition? YesNo Coronary Artery Disease:* YesNo Do you take medication to control this condition?* YesNo Congestive Heart Failure * YesNo Do you take medication to control this condition?* YesNo Depression* YesNo Stroke* YesNo Adrenal Hyperplasia * YesNo Date of last physical * —Please choose an option—Within the last 6 monthsWithin the last year2 years ago or more Stress Level * HIGHMEDLOW Have you ever had a scalp biopsy? A scalp biopsy is when a physician removes of a small portion of scalp from the patient’s head which is then sent to a lab for testing. * YesNo Was a diagnosis made? YesNo Select DiagnosisNoAndrogenetic AlopeciaAlopecia AreataAlopecia TotalisAlopecia UniversalisCicatricial AlopeciaTelogen EffluviumAnagen EffluviumTinea CapitisLichen PlanopilarisLupus ErythematosusFolliculitis DecalvansDissecting Cellulitis of The ScalpFrontal Fibrosing AlopeciaCentral Centrifugal Cicatricial AlopeciaLoose Anagen SyndromeTrichotillomaniaTraction AlopeciaHypotrichosisNone of these Do you currently have any dysplastic or malignant lesions on your scalp?* YesNo Bloodwork: Have you had any of these tests done in the past 6 months? CBC (Complete Blood Count)* YesNo Hormone: DHEA/Testosterone/Estrogen * YesNo Thyroid Panel: * YesNo Glucose: * YesNo Vitamin D: * YesNo Was Vitamin D in a normal range? * YesNoUnknown Iron: * YesNo Was it in a normal range? YesNoUnknown Have you ever been diagnosed with any type of Anemia? YesNo Have you ever been diagnosed with Thyroid Disease?:* YesNo Do you take thyroid medication? YesNo Has a Physician ever recommended you take thyroid medication? YesNo Does anyone else in your family have a history of Thyroid disease? YesNoUnknown Females Only: Postmenopausal: * YesNo Are you planning on becoming pregnant in the next 6 months? * YesNo Are you currently pregnant or nursing?* YesNo Have you ever been diagnosed with PCOS?* YesNo Males Only: Have you had or do you plan to take a PSA blood test for the screening of prostate cancer? * YesNo Do you have an enlarged prostate or prostate cancer? * YesNo Has your doctor tested your testosterone levels? * YesNo Was the Testosterone result in a normal range?* YesNo Has your doctor tested your Estrodiol levels? * YesNo Nutrition: Are you a vegetarian? * YesNo How many 3oz servings of protein do you eat per day? * 0123 or more How many cups of fruits & vegetables combined do you eat per day? * 012345 or more Have you gained or lost weight recently? * GainedLostNo Change Conditions of Hair and Scalp:* Select the hair loss stage which best describes your current hair loss pattern: * —Please choose an option—IIIII-AIIIIII-AIII-vertexIVIV-AVV-AVIVIICompletely Bald HeadOverall Thinning —Please choose an option—12345678Completely Bald HeadFrontalOverall Thinning Scalp Condition: * DryOilyNormal Painful Itchy Scalp: * YesNo Bumps or Raised Areas: * YesNo Redness Only: * YesNo Itchy Scalp Only: * YesNo Goosebump Feeling: * YesNo Dandruff: * YesNo Do you pull out your hair? * YesNo Recurrent Attacks of Patchy Loss: * YesNo Are you aware of any open sores or abrasions on your scalp?* YesNo Were you ever DIAGNOSED BY A PHYSICIAN for any of the following: Select DiagnosisNoAndrogenetic AlopeciaAlopecia AreataAlopecia TotalisAlopecia UniversalisCicatricial AlopeciaLichen PlanopilarisFolliculitis DecalvansDissecting Cellulitis of The ScalpFrontal Fibrosing AlopeciaDiscoid Lupus ErythematosusCentral Centrifugal Cicatricial AlopeciaHypotrichosisTelogen EffluviumAnagen EffluviumTinea CapitisMale Pattern BaldnessFemale Pattern BaldnessNone of these How long has your hair loss been occurring?* —Please choose an option—3 months or less3- 6 months6-12 months1-2 years2 years or more How many hair strands per day do see in shower/counter? * —Please choose an option—3 or less4 - 67- 910 or more To your knowledge does your shampoo contain SLS (Sodium Laurel Sulfate or Sodium lauryl Sulfate) or DEA? * YesNoUnknown How many times a week do you shampoo your hair? * —Please choose an option—1-34 - 67 or more Following each shampoo do you use a conditioner? * YesNo What speed did you lose your hair? * GradualSuddenly Body Hair Loss? * ArmsArmpitsLegsPubic AreaChestNone Is your hair loss getting worse? * YesNo When your hair is wet, do you use a towel to rub dry? * YesNo Heredity Information: Mother * BaldThinningNormalUnknown Grandmother* BaldThinningNormalUnknown Siblings* BaldThinningNormalUnknown Father* BaldThinningNormalUnknown Grandfather* BaldThinningNormalUnknown Aunts* BaldThinningNormalUnknown Uncles* BaldThinningNormalUnknown What options have you utilized for your hair loss including over the counter medications and prescriptions? * Hair TransplantsScalp TreatmentHair ReplacementRogaine or MinoxidilPropecia or FinasterideNone How long since your transplant? More than 12 monthsLess than 12 months Are you currently wearing hair? NoYes Are you currently using Rogaine or Minoxidil? NoYes How long have you been using it? 2 months or less3 months or more Check all that apply. Did you experience any of the following prior to the onset of your hair loss?* —Please choose an option—An illness which required hospitalizationA severe infection which required antibioticsA case of Covid-19A severe inflammation flare-upNone Did you experience any of the following prior to the onset of your hair loss?* —Please choose an option—A doctor's diagnosis of a diseaseDeath of a loved oneDivorce or threat of divorceCaring for an ill childCaring for an ill and/or elderly parentA physical attack on yourself or a loved oneNone Have you ever had any type of eating disorder? * YesNo Are you presently taking any medications? * YesNo Do you smoke? * YesNo Are you currently being treated BY A PHYSICIAN for a hair or scalp problem? * YesNo Have you ever tried any of the following for at least 6 months? * RogainePropecia or FinasterideHair TransplantNone Did you get any positive results from using Rogaine for 6 months? YesNo Did you get any positive hair growth results from taking Propecia or Finasteride for 6 months? YesNo Did you gain any new growth following the hair transplant? YesNo Have you ever had a negative or allergic reaction to SHELLFISH or ZINC? * YesNo Expectations: We do not agree to work with everyone because not everyone is a good candidate for what we offer. To determine if you are a good candidate, let us know your answer to the following: If a plan existed that would completely stop your hair loss and help you grow more hair, which outcome would meet your expectations and make you happy? 1. I would be happy to stop my hair loss and keep it from getting any worse.2. I would be happy to stop my hair loss and see a little less scalp in my thinnest area.3. I would be happy to stop my hair loss and see a lot less scalp in my thinnest area.4. I would be happy to stop my hair loss and see no scalp in my thinnest area.5. I will only be happy if my hair loss stops and I get all of my missing hair back. Please provide any additional comments here: 1000 I acknowledge that I have answered all questions truthfully and to the best of my ability. * Write your full name to sign. Date * ATTENTION: Before you submit, please add [email protected] to your contacts and whitelist to prevent your customized report from going into your spam folder. Δ
