Email Address:

Home Phone:

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Address:

Address:

City:

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Your Age:

Have you seen a physician regarding your hair loss problem? Select one Yes No

Does thinning hair run in your family? Select one Yes No

Do you have any skin allergies? Select one Yes No
If so, what?

Have you ever dyed, bleached or permanent waved your hair during the last six months? Select one Yes No

When did you first notice your hair loss problem?

Do you have chronic dandruff? Select one Yes No
Do you have chronic psoriasis? Select one Yes No

Have you ever considered any other type of hair replacement before visiting Hair Loss Solutions?
Select one Yes No
If yes, describe:

How does your hair loss affect you in these situations?
(Please describe)
In your social life:

In your occupation:

On a windy day:

On a beach or ocean:

Meeting new people:

Maintaining your overall appearance?

How did you hear about us?
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