test-form

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: *
---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

Coronary Artery Disease:*
YesNo

Congestive Heart Failure *
YesNo

Depression*
YesNo

Stroke*
YesNo

Adrenal Hyperplasia *
YesNo

Date of last physical *
---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

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

Thyroid Panel: *
YesNo

Glucose: *
YesNo

Vitamin D: *
YesNo

Iron: *
YesNo

Have you ever been diagnosed with any type of Anemia?
YesNo

Have you ever been diagnosed with Thyroid Disease?:*
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: *

---IIIII-AIIIIII-AIII-vertexIVIV-AVV-AVIVIICompletely Bald HeadOverall Thinning

---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?*
---3 months or less3- 6 months6-12 months1-2 years2 years or more

How many hair strands per day do see in shower/counter? *
---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? *
---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

Check all that apply.

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

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

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

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 *

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