Hair-loss Evaluation Form

We need to know a little bit about you & how you want to be reached...










ADDRESS







Now we need a little history on your hair health

Is your hair finer or thinner than it once was?

Have you changed the way you style your hair to try to conceal hair thinning?

Have you found more hair than normal on your pillow, brush or shower drain?

If you tie a ponytail, is the circumference of the ponytail smaller than it was before?

In the part down the middle of your scalp, does the width of the part show more scalp than normal?

Have members of your immediate or extended family, male or female, experienced hair loss?

Have you sought professional or other advice for your hair?

Select which of the following treatment options, if any, you've considered for hair loss

Select which of the following treatment options, if any, you have undergone.

Otherwise healthy