Hair Loss Questioraire
Fill-out the following form and a staff member will respond to you shortly with the best solutions specific for you.
First Name:
Last Name:  
Date of Birth:

1. How long have you been losing your hair?
1-3 years 3-7 years 7-15 years more than 15 years

2. Where has the hair loss occurred?
(A) (B) (C) (D) (E)

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

4. Do you suffer from..? (choose as many as applicable)
dandruff itchy scalp dry scalp oily scalp

5. Would you characterize your existing hair as..(choose one)
Dry Oily Normal

6. Is the hair growing on the sides of your head? (choose one)
thin and full thick and full thin and slightly receding

7. Does your scalp excrete excessive sebum (oils)?
Yes No

8. Have you ever experienced a build-up of sebum (oil) on your scalp?
Yes No

9. Does your scalp ever flake?
Yes No

10. Do you ever see red blotches on your scalp?
Yes No

11. How would you rate your current rate of hair loss? (choose one)
light moderate Heavy

12. Have you experienced an increase in your rate of hair loss in the past year?
Yes No

13. Have you ever tried to do anything about your hair loss?
Rogaine Hair Transplant Hair Replacement Lotions/Shampoos

14. Have you ever seen a doctor about your hair loss?
Yes No

15. Has anyone ever mentioned your hair loss to you?
Wife Girlfriend Husband Boyfriend Mother Father Other

16. Does that bother you?
Yes No

17. Why do you want to do anything about your hair?
I look older than I feel I hate the way my hair looks I want to meet younger men/women People make fun of me

18. Do you want to:
Stop your hair loss? Have more hair?

When you are ready to submit the above information just click on the button below.

Phone (201) 935-7720   Fax: (201) 935-1076   Email:   Address: 36 Spring Dell, Rutherford, NJ 07070