Comprehensive Evaluation

First Name (required)

Last Name (required)

Email (required)

Phone Number

Address

City

State/Province
Michigan Ohio Ontario ————— Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Oklahoma Oregon Pennsylvania Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Zip/Postal Code

Country
— United States Canada

How would you like to be contacted?
 Phone
 Email
 Postal

Gender:
Male Female

Type of hair (ethnicity):
— White/Caucasian Afro/Caribbean Indian Asian Arab

What best describes your hair loss condition?
— Male Pattern Baldness Female Pattern Baldness Thinning Hair Receding Hairline Medical Condition Related Alopecia Totalis Alopecia Areata Alopecia Universalis Chemotherapy Related Not Sure

How long have you been experiencing hair loss?
 1-3 Years
 3-7 Years
 7-15 Years

Is your scalp visible in the area where you have lost your hair?
 Yes
 No

Do you suffer from any of the following conditions? (Choose all that apply)
 Dandruff
 Itchy Scalp
 Dry Scalp
 Oily Scalp
 Excessive Shedding

Have you attempted to do anything about your hair loss situation? (choose all that apply)
 Rogaine/Propecia
 Hair Transplant
 Herbal Solution
 Hair Extensions
 Hair Systems
 Lotions/Shampoos
 Nothing

Have you consulted a doctor or other professional about your hair loss?
 Yes
 No

How often do you think about your hair loss situation?
 Not much
 Sometimes
 All the time

Does your hair loss situation ever make you feel depressed?
 Yes
 No

Do you feel that your hair loss prohibits you from being "who you really are"?
 Yes
 No

Do you feel that your hair loss adversely affects your self-confidence?
 Yes
 No

Do you feel that your hair loss adversely affects your self-esteem?
 Yes
 No

In which areas of your life do you feel your hair loss adversely impacts you? (Choose all that apply)
 Home Life
 Work Life
 Social Life
 Dating
 Intimacy
 None

Are you ready to do something about your hair loss immediately?
 Yes
 No

Please offer us any additional information and/or comments regarding your hair loss: