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.

Coronary Artery Disease:
YesNo
Please fill the required fields.

Congestive Heart Failure:
YesNo
Please fill the required fields.

Stroke:
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.

Are you presently taking any medications?
YesNo
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.

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.

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.

Thyroid Panel:
YesNo
Please fill the required fields.

Glucose:
YesNo
Please fill the required fields.

Vitamin D:
YesNo
Please fill the required fields.

Iron:
YesNo
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.

Have you ever had a scalp biopsy?
YesNo
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.

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.