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    This is to make sure we ask the right questions.



    Have you had any surgery within the last year with General Anesthesia? *

    Do you have any of the following medical problems?

    Irregular Heartbeat *

    Do you take medication to control this condition?

    Coronary Artery Disease:*

    Do you take medication to control this condition?*

    Congestive Heart Failure *



    Adrenal Hyperplasia *

    Date of last physical *

    Stress Level *

    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. *

    Was a diagnosis made?

    CBC (Complete Blood Count)*

    Hormone: DHEA/Testosterone/Estrogen *

    Thyroid Panel: *

    Glucose: *

    Vitamin D: *

    Was Vitamin D in a normal range? *

    Iron: *

    Was it in a normal range?

    Have you ever been diagnosed with any type of Anemia?

    Check all that apply.

    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:


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