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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? * YesNo
    Do you have any of the following medical problems? Irregular Heartbeat * YesNo
    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?

    Overall Thinning I II III III-A III-vertex IV IV-A V V-A VI VII Completely Bald Head
    Overall Thinning 1 2 3 4 5 6 7 8 Completely Bald Head

    Check all that apply.
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