multi-form Please select your gender first: MaleFemale This will make sure we ask the right questions. Please fill the required fields. Age: Please fill the required fields. Medical History Describe your overall general health: ---Excellent healthGood healthPoor health Please fill the required fields. Have you had any surgery within the last year with General Anesthesia? YesNo Please fill the required fields. Do you have any of the following medical problems? Irregular Heartbeat: YesNo Please fill the required fields. Do you take medication to control this condition? YesNo Please fill the required fields. Coronary Artery Disease: YesNo Please fill the required fields. Do you take medication to control this condition? YesNo Please fill the required fields. Congestive Heart Failure: YesNo Please fill the required fields. Do you take medication to control this condition? YesNo Please fill the required fields. Stroke: YesNo Please fill the required fields. Do you take medication to control this condition? YesNo Please fill the required fields. Adrenal Hyperplasia: YesNo Please fill the required fields. Date of last physical: ---Within the last 6 monthsWithin the last year2 years ago or more Please fill the required fields. Have you ever been diagnosed with any type of Anemia? YesNo Please fill the required fields. Have you ever been diagnosed with Thyroid Disease? YesNo Please fill the required fields. Do you take thyroid medication? YesNo Please fill the required fields. Has a Physician ever recommended you take thyroid medication? YesNo Please fill the required fields. Does anyone else in your family have a history of Thyroid disease? YesNoUnknown Please fill the required fields. Are you presently taking any medications? YesNo Please fill the required fields. What medications are you taking? Please fill the required fields. Do you smoke? YesNo Please fill the required fields. Have you ever had a negative or allergic reaction to SHELLFISH or ZINC? YesNo Please fill the required fields. Have you ever been diagnosed with an auto-immune disorder? YesNo Please fill the required fields. What auto immune disorder? Please fill the required fields. Biological Male Have you had or do you plan to take a PSA blood test for the screening of prostate cancer? YesNo Please fill the required fields. Do you have an enlarged prostate or prostate cancer? YesNo Please fill the required fields. Has your doctor tested your testosterone levels? YesNo Please fill the required fields. Was the Testosterone result in a normal range? YesNo Please fill the required fields. Has your doctor tested your Estradiol levels? YesNo Please fill the required fields. Biological Female Postmenopausal: YesNo Please fill the required fields. Are you planning on becoming pregnant in the next 6 months? YesNo Please fill the required fields. Are you currently pregnant or nursing? YesNo Please fill the required fields. Have you ever been diagnosed with PCOS? YesNo Please fill the required fields. Emotional and Physical Distress Did you experience any of the following prior to the onset of your hair loss? ---An illness which required hospitalizationA severe infection which required antibioticsA case of Covid-19A severe inflammation flare-upNone Please fill the required fields. Did you experience any of the following prior to the onset of your hair loss? ---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 Please fill the required fields. Do you suffer with depression? YesNo Please fill the required fields. Do you take medication to control this condition? YesNo Please fill the required fields. Stress Level: HighMediumLow Please fill the required fields. Bloodwork: Have you had any of these tests done in the past 6 months? CBC (Complete Blood Count): YesNo Please fill the required fields. Hormone DHEA/Testosterone/Estrogen: YesNo Please fill the required fields. Thyroid Panel: YesNo Please fill the required fields. Glucose: YesNo Please fill the required fields. Vitamin D: YesNo Please fill the required fields. Was Vitamin D in a normal range? YesNoUnknown Please fill the required fields. Iron: YesNo Please fill the required fields. Was it in a normal range? YesNoUnknown Please fill the required fields. Nutrition Have you ever had any type of eating disorder? YesNo Please fill the required fields. Are you a vegetarian? YesNo Please fill the required fields. How many 3oz servings of protein do you eat per day? 0123 or more Please fill the required fields. How many cups of fruits & vegetables combined do you eat per day? 012345 or more Please fill the required fields. Have you gained or lost weight recently? GainedLostNo Change Please fill the required fields. Has your doctor ever indicated you may have nutrient malabsorption? Malabsorption definition: Difficulty in the digestion or absorption of nutrients from food. YesNoUnknown Please fill the required fields. Hair Loss Stage Select the hair loss stage which best describes your current hair loss pattern: ---IIIII-AIIIIII-AIII-vertexIVIV-AVV-AVIVIICompletely Bald HeadOverall Thinning Please select the hair loss stage which best describes your current hair loss pattern. ---12345678Completely Bald HeadFrontalOverall Thinning Please select the hair loss stage which best describes your current hair loss pattern. Conditions of Hair and Scalp Scalp Condition: DryOilyNormal Please fill the required fields. Painful Itchy Scalp: YesNo Please fill the required fields. Bumps or Raised Areas: YesNo Please fill the required fields. Redness Only: YesNo Please fill the required fields. Itchy Scalp Only: YesNo Please fill the required fields. Goosebump Feeling: YesNo Please fill the required fields. Dandruff: YesNo Please fill the required fields. Do you pull out your hair? YesNo Please fill the required fields. Recurrent Attacks of Patchy Loss: YesNo Please fill the required fields. Are you aware of any open (bleeding and/or oozing) sores, lesions, or abrasions on your scalp? YesNo Please fill the required fields. Do you currently have any dysplastic or malignant lesions on your scalp? YesNo Please fill the required fields. Have you ever had a scalp biopsy? YesNo Please fill the required fields. Was a diagnosis made? YesNo Please fill the required fields. What was your diagnosis? ---NoAlopecia AreataAlopecia TotalisAlopecia UniversalisAndrogenetic AlopeciaAnagen EffluviumCentral Centrifugal Cicatricial AlopeciaCicatricial AlopeciaDiscoid Lupus ErythematosusDissecting Cellulitis of The ScalpFemale Pattern BaldnessFolliculitis DecalvansFrontal Fibrosing AlopeciaHypotrichosisLichen PlanopilarisLoose Anagen SyndromeMale Pattern BaldnessTinea CapitisTelogen EffluviumTrichotillomaniaTraction AlopeciaNone of these Please fill the required fields. What was your diagnosis? Please fill the required fields. Were you ever DIAGNOSED BY A PHYSICIAN with any of the following? ---NoAlopecia AreataAlopecia TotalisAlopecia UniversalisAndrogenetic AlopeciaAnagen EffluviumCentral Centrifugal Cicatricial AlopeciaCicatricial AlopeciaDiscoid Lupus ErythematosusDissecting Cellulitis of The ScalpFemale Pattern BaldnessFolliculitis DecalvansFrontal Fibrosing AlopeciaHypotrichosisLichen PlanopilarisLoose Anagen SyndromeMale Pattern BaldnessTinea CapitisTelogen EffluviumTrichotillomaniaTraction AlopeciaNone of these Please fill the required fields. Are you currently being treated BY A PHYSICIAN for a hair or scalp problem? YesNo Please fill the required fields. Hair Loss History: What speed did you lose your hair? GradualSuddenly Please fill the required fields. How long has your hair loss been occurring? ---3 months or less3- 6 months6-12 months1-2 years2 years or more Please fill the required fields. Body Hair Loss: Check all that apply. ArmsArmpitsLegsPubic AreaChestNone Please fill the required fields. Is your hair loss getting worse? YesNo Please fill the required fields. Shampoo habits How many times per week do you shampoo your hair? ---1-34 - 67 or more Please fill the required fields. Following each shampoo, do you use a conditioner? YesNo Please fill the required fields. When your hair is wet, do you use a towel to rub it dry? YesNo Please fill the required fields. How many hair strands per day do you see in the shower drain? ---3 or less4 - 67 - 910 or more Please fill the required fields. To your knowledge, does your shampoo contain SLS (Sodium lauryl Sulfate or Sodium Laureth Sulfate) or DEA? YesNoUnknown Please fill the required fields. Heredity Information Mother: BaldThinningNormalUnknown Please fill the required fields. Grandmother: BaldThinningNormalUnknown Please fill the required fields. Siblings: BaldThinningNormalUnknown Please fill the required fields. Father: BaldThinningNormalUnknown Please fill the required fields. Grandfather: BaldThinningNormalUnknown Please fill the required fields. Aunts: BaldThinningNormalUnknown Please fill the required fields. Uncles: BaldThinningNormalUnknown Please fill the required fields. What other options have you utilized to help with your hair loss? Hair TransplantsScalp TreatmentHair ReplacementRogaine or MinoxidilPropecia or FinasterideNone Please fill the required fields. Did you gain any new growth following the hair transplant? YesNo Please fill the required fields. Are you currently wearing hair? YesNo Please fill the required fields. Are you currently using Rogaine or Minoxidil? YesNo Please fill the required fields. Have you been consistently using it for more than 6 months? YesNo Please fill the required fields. Did you get any positive results from using Rogaine or Minoxidil for 6 months? YesNo Please fill the required fields. Are you currently taking Propecia or Finasteride? YesNo Please fill the required fields. Have you been consistently using it for more than 6 months? YesNo Please fill the required fields. Did you get any positive hair growth results from taking Propecia or Finasteride for 6 months? YesNo Please fill the required fields. Expectations We do not agree to work with everyone because not everyone is a viable candidate to regrow lost hair. To determine if you are a good candidate, let us know your answer to the following: If a plan existed that would reverse your hair loss and grow more hair, which outcome would meet your expectations and make you happy? 1. I will be happy to stop my hair loss and see steady improvement to my hair density over time.2. I will only be happy if my hair loss stops and I get all of my missing hair back. Please fill the required fields. Contact info First Name Last Name Email Address Confirm Email Address Your emails do not match. Please provide any additional comments here: 1000 I acknowledge that I have answered all questions truthfully and to the best of my ability. Type your full name to sign. Date ATTENTION: Before you submit, please add [email protected] to your contacts and/or whitelist to ensure you never miss an email from us. Thank you for your submission. Please wait while your customized report is generated. BackNext Δ
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