Date of birth
Where have you noticed hair thinning or loss?
How long have you had hair loss or thinning?
less than 1 year
between 1 and 3 years
longer than 3 years
Have you been diagnosed with alopecia or any skin conditions?
Does anyone in your family suffer from hair loss?
Do you have any health issues or illnesses?
If yes, please detail any medical complaints here
Please list any medications that you currently take
Do you have any allergies?
If yes, the please detail your allergies