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Hair Quiz

First Name

Last Name

Phone *

Email *

Are you experiencing excessive shedding and/or hair loss? *

Yes

How Long have you been experiencing hair loss or excessive shedding? *

Have you been diagnosed with any form of Alopecia? (check all that applies)

Alopecia Areata

Scarring Alopecia

Androgenic Alopecia

Telogen Effluvium

Traction Alopecia

Are you experiencing any of the following? (check all that applies)

Itching

Severe itching

Burning

Tender to touch scalp

Do you suffer from any of the following? ( Check all that applies) *

Fibroids

PCOS

Heart Disease

Hypertension

Cancer

Thyroid Dysfunction

Diabetes

Stress

Anxiety

Depression

None

Are you deficient in any of the essential vitamins and minerals for hair growth? (Check all that applies) *

Vitamin D

Iron

Zinc

Ferritin

Selenium

Folate

B complex (Biotin, B-12, B-1, B-2, B-3, B-5, B-6, B-9,

Unknown

Are you aware hair loss start in the GUT? *

Yes

Is there Genetic history or Male/Female pattern baldness? *

Yes

Are you Interested in booking a hair loss consultation?

Yes

Which approach are you willing to take ? *

Chemical Approaches

Holistic Apporaches

Lasers

All of the above

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