First Name:
Last Name:
Geneder :
Male
Female
Age :
Date of Birth : Month:
Day:
Year :
Company Name:
Address :
City :
State :
Country :
Zip Code :
Telephone # :
Email Address :
2. Any particular medical conditions? Yes :
No :
If Yes, please describe it:
3. How long have you been experiencing hair loss?
Years.
4. How extensive is your baldness?
Minor :
A small amount of diffuse thinning of the hair and
or/slight amount of recession of the frontal hairline
and/or a small bald spot on the top back of the
head.
Moderate:
A fair amount of diffuse thinning of the hair and
or a fair amount of recession of the frontal hairline
and/or a moderate sized bald spot on top back of
head.
Extensive:
Extensive diffuse thinning of the hair, and/or a
large bald spot on the top back of the head.
Frank Baldness:
No hair on the front or back of the scalp except
for a horseshoe pattern above the ears and in the
back of the head.
5. If your hair loss was the result of a medical
condition other than genetic male or female pattern
baldness, please describe the condition:
6. When did you notice significant hair loss?
7. Have you used any other hair loss product? Yes:
No :
If yes, product name:
Describe the results:
8.. Are you presently using any other hair loss treatment?
Yes.
No.
If Yes, Product Name:
9. How did you hear about us?
Advertisement :
Magazine:
Internet :
Friend :
Others :
