Hair Loss Questionnaire We would love to hear from you! Please fill out this form and remember there are no wrong answers. We will get in touch with you shortly. Name* First Last Phone*Email* How many years has it been since your hair loss became noticeable to you? 0-3 years 4-7 years 8-10 years 11-15 years 16+ years Has your hair loss been: Gradual Sudden At any time, have you used any of the following products? Treatment Shampoos Propecia (Men) Rogaine None Have you had hair transplants or scalp reduction? Yes No Which of the following does your diet mostly consist of? Fresh, home cooked food Restaurant meals Fast food Describe your alcohol consumption: A couple of drinks a month Several per week Daily Rare - never How many times per week do you exercise? Once per week 2-3 times 4-6 times Daily NameThis field is for validation purposes and should be left unchanged.
