Hair Health Questionnaire "*" indicates required fields Name* Phone Number*Email* GenderMaleFemalePhoto UploadTopMax. file size: 2 MB.Left SideMax. file size: 2 MB.Right SideMax. file size: 2 MB.When did you first notice your hair loss?*Please select...Less than 6 months ago6-12 months ago1-2 years ago2+ years agoWhere is the primary area of your hair loss? (select all that apply)* Hairline (front of scalp) Crown/Vertex (top of scalp) Patchy (small concentrated areas all over scalp) Diffuse (evenly distributed thinning all over scalp) Do you experience any of the following? (select all that apply) Itching, burning, bumps, or rashes on your scalp Hair loss from areas other than head Sudden, recent increase in hair loss Dandruff, scaling, or greasiness on your scalp Other skin rash, itchiness, discoloration What treatments have you tried for your hair loss? (select all that apply) Minoxidil Shampoos Hair Transplant Surgery Finasteride Laser or Light Therapy Spironolactone Platelet Rich Plasma injections Exosomes None Nutritional supplements (please list) Other (please describe) Nutritional supplements (please list) Other (please describe) Have you ever seen a medical professional for your hair loss? Yes No What is the name of the doctor or other medical professional you have seen?
