Loading...

Consult Questionnaire

Consent for treatment

I am being evaluated by The Primping Place and understand I will first undergo a comprehensive preliminary evaluation by one of our experienced hair loss consultants and may talk to a doctor should I need a prescription product. This evaluation will determine if I am a suitable candidate for treatment prior to having my chart reviewed by a physician.  I understand that the cost of the initial evaluation is FREE and The Primping Place has waived its $250 consultation fee. This preliminary evaluation will include a complete and thorough medical and hair loss questionnaire, a scalp evaluation if available which includes standard medical photography (no face shown), and microscopic photography for which I give consent. I also understand that although HLCC/ XTC™ has had many extremely successful clients, each client is different and like any medical or cosmetic treatment results will vary depending on a large number of factors. I acknowledge that it is my responsibility to inform The Primping Place of any changes in my medical condition no matter how slight and agree to read all product labels and treatment information provided to me so I can  understand my treatments and get the best possible results.

I understand some general recommendations will be made based on the initial consultation and if it is determined that I am a candidate for a prescription treatment program; an appointment will be made with one of the clinic’s doctors. I also understand it is my responsibility to keep my appointment with the doctor.

Cancellation Policy:
Please give us a 4 hour notice or you will be charged a $25 no-show fee.

Today's Date: December 13, 2018

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age

Occupation
Referred by:*

If other:

Medical History


Allergies
Are you allergic to shellfish?*
No
Yes

General Health

Previous Surgery with General Anesthesia
Do you have any of the following medical problems?
Stroke
Congestive Heart Failure
Irregular Heart Beat
Coronary Artery Disease
Hypertension (High Blood Pressure)
Anemia
Depression
Thyroid Disease

Presently Undergoing Medical Treatment for

Physician's name

Date of last physical
Stress*
Bloodwork: Have you had any of these tests done in the past year?
CBC w/Diff
Thyroid Panel
Glucose Tolerence
Ferritin/Iron test
Hormone: DHEA/Testosterone /Estrogen
Other

If other:

Medications: Please list the name of any medication (or supplement) and dosage you take daily

Females Only

Female issues
Yes
No
Post Meonpausal
Yes
No
Are you currently pregnant or nursing?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate, prostate cancer?
Yes
No

Nutrition

Are you a vegetarian?*
No
Yes

How many servings of protein do you get a week?

Serving red meat per week

Snacks
Gained or lost weight recently?*

How much?

Conditions of Hair and Scalp

Scalp*
Redness*
No
Yes
Dandruff*
No
Yes
Painful itchy scalp:*
No
Yes
Itchy scalp only:*
No
Yes
Do you pull your hair?*
No
Yes
Bumps or raised areas:*
No
Yes
Goose Bump feeling:*
No
Yes
Recurrent attacks of patchy loss:*
No
Yes
Hair of different length*
No
Yes
Areas of hair loss:
All over scalp
Front
Crown
Alopecia Areata
Totalis
Universalis
Did you lose any hair at a young age?*
No
Yes

How old were you?
Any loss of hair on body?*
No
Yes

What area

At what age did you notice hair loss?
Was loss sudden or gradual?*
Is your hair loss getting worse?*
No
Yes

How many hairs lost per day?

What kind of shampoo do you use?

Conditioner

How many times per week do you shampoo?
Do you use a hair dryer?*
No
Yes
What temperature?*
When hair is wet, do you use a towel to rub dry?*
No
Yes

Is your hair loss caused by any medical problems or medications that you are aware of?
HEREDITY Does hair loss run in your family?*
No
Yes
Parents*
Grandparents*
Siblings*
Aunt/Uncle*
What options have you researched for your hair loss (Including over the counter and prescriptions)?
Transplants
Scalp Treatments
Hair Replacement or weaves
Over the counter products
Prescription products
Avacor
Minoxidil (%)
Clubs or Hair Loss Clinics
Other

If other:
How much does your hair loss bother you?*
Would you like to consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost*
No
Yes
What are your goals and expectations?
Prevent further loss
Gain back hair quickly
Gradually gain back some hair
Other

Other
Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver