Ready to stop hair loss and regrow lost hair?

Submit your 5-minute assessment to evaluate your hair growth potential.

It’s simple and FREE and we never sell your info to anyone!

Hair loss contributors must be identified & effectively combatted for successful hair regrowth to occur.

The latest technology in the ongoing hair loss battle: The Trichology Assessment

Developed by hair transplant surgeons and certified trichologists
Your assessment will uncover hair loss contributors
Your assessment will evaluate your hair growth potential
Your assessment will provide an effective plan for hair recovery

Hair loss can be caused by various contributors and without effective intervention, it will simply get worse.

Please be as accurate as possible in providing your answers as they will determine the accuracy of your final report.

ALL questions are mandatory for your assessment.

Once your submission is received, one of our certified trichologists will reach out to you.

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: *

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 *

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

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? *

How many cups of fruits & vegetables combined do you eat per day? *

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: *

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:

How long has your hair loss been occurring?*

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

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? *

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?

Are you currently wearing hair?

Are you currently using Rogaine or Minoxidil?

How long have you been using it?

Check all that apply.

Did you experience any of the following prior to the onset of your hair loss?*

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 *

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