How long have you been losing your hair?
1-2 years 3-7 years 7-15 years more than 15 years

Where has the hair loss accrued?
(A) (B) (C) (D) (E)


Is the scalp visible in the area where you have lost your hair?
Yes No

Do you suffer from..? (choose as many as applicable)
dandruff itchy scalp dry scalp oily scalp

Would you characterize your existing hair as.(choose one)
Dry Oily Normal

Is the hair growing on the sides of you head? (choose one)
thin and full thick and full thin and slightly receding

Does your scalp excrete excessive sebum (oils)?
Yes No

Have you ever experienced a build-up of sebum (oil) on your scalp?
Yes No

Does your scalp ever flake?
Yes No

Do you ever see red blotches on your scalp?
Yes No

How would you rate your current rate of hair loss? (Choose one)
light moderate heavy

Have you experienced an increase in your rate of hair loss in the past year?
Yes No

Have you ever tried to do anything about your hair loss?
Rogaine Hair Transplant Hair Replacement Lotions/Shampoos Nothing

Have you ever seen a doctor about your hair loss?
Yes No

Has anyone ever mentioned your hair loss to you?
Wife Girlfriend Husband Boyfriend Mother Father Other

Does that bother you?
Yes No

Why do you want to do anything about your hair?
I look older than I feel I hate the way my hair looks
I want to meet younger men/women People make fun of me