Online Hair Loss Test

Name *

First Name

Last Name

Your Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What type of hairloss? *

Head/Scalp

Beard

Eyebrows

Other

Has it worsened recently? *

Yes

No

Is your hair loss? *

Diffuse, Thinning, Scattered

Patchy

Other

Do you have a family history of hair loss? *

Yes

No

Describe your general health: *

Good

Average

Poor

Past medical history. Have you have any of the following? *

Anaemia. Iron Deficency

Autoimmune Disorder

Arthritis

Inflammatory Bowel Disease

Diabetes

Thyroid Disease (Over & Under active)

Kidney Disease

Liver Disease

Cancer

Radiation or Chemotherapy

Mental Illness

Depression

Emotional Stress or Anxiety

Hair Transplant

Previous Hair Loss Treatments

Post Pregnancy

Skin Infections - Fungal, Bacterial, Viral, Chronic HSV

Significant Illness or Disease

Significant Trauma

Significant Surgery

Significant Weight Loss

Other

NONE OF THESE

For women, do any of the following apply?

Post Pregnancy

Polycystic Ovarian Syndrome

Trouble with acne, oily skin

Growth of facial and body hair

On oral contraception

None of the above

Dietery considerations. Tick any that apply *

Vegetarian

High processed carb intake

High GI food intake

Dieting recently

Iron Deficiency

Nutritional Deficency

Zinc Deficency

High Vitamin A intake

High Why Protein intakes

Testosterone Boosters or Analogues

NONE OF THE ABOVE

Lifestyle. Do you exercise? *

Yes

No

Do you smoke? *

Yes

No

Are there any treatments that are of interest to you? *

These are the range of treatments with proven effect for Hair Growth. For Hair Transplants which are done typically Norwood Scale 5-7 we can facilitate a referral to our Hair Transplant Surgeon.

Minoxidil

Finasteride

PRP

Mesotherapy

Regenera Activa

PDO Threads

Light Therapy

Hair Transplant

Unsure

Like to find out more about what you offer

Are you happy for our Doctor to contact you about this? *

Yes