1. How long have you been losing your hair?
more than 15 years
2. Where has the hair loss occurred?
3. Is the scalp visible in the area where you have
lost your hair?
4. Do you suffer from..? (choose as many as
5. Would you characterize your existing hair as..(choose
6. Is the hair growing on the sides of your head? (choose
thin and full
thick and full
thin and slightly receding
7. Does your scalp excrete excessive sebum (oils)?
8. Have you ever experienced a build-up of sebum
(oil) on your scalp?
9. Does your scalp ever flake?
10. Do you ever see red blotches on your scalp?
11. How would you rate your current rate of hair
loss? (choose one)
12. Have you experienced an increase in your rate
of hair loss in the past year?
13. Have you ever tried to do anything about your
14. Have you ever seen a doctor about your hair
15. Has anyone ever mentioned your hair loss to
16. Does that bother you?
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?