Online Diagnostic Form Title(required) Mr. Mrs. Miss. Ms. Dr. Name(required) Address(required) Address2 PostCode(required) Email(required) Confirm Email(required) Date Of Birth(required) Sex(required) Male Female Which Picture best indicates the type of hair loss you are suffering from? Type of hair loss(required) I II III IV V How long have you been suffering from hair loss? Time(required) less than 1 year 1-2 years 3-4 years 5 years or more Approx how much hair are you left with on the head?(required) under 25% 25 - 50% 50 - 75% over 75% Have you experienced total hair loss on body?(required) No Yes Is there a history of hair loss in your family?(required) Yes No If so which member:(required) not applicable father mother grandparents uncle brother/sister Is your hair type?(required) Caucasian/White African Asian Other Are you under constant pressure/stress?(required) No Yes Are you taking any medication (including non-prescription)? (required) No Yes If yes, please enter details in comments area Have you used any treatments for hair loss?(required) No Yes If yes, please enter details in comments area Do you suffer from any allergies?(required) No Yes If yes, please enter details in comments area Have you ever been checked for (or diagnosed with) prostate cancer?(required) No Yes If yes, please enter details in comments area Have you ever been checked for (or diagnosed with) liver problems?(required) No Yes If yes, please enter details in comments area Comments; Please use this field to add details or to expand further on the above questions if necessary, or to tell us more about your problem so that our doctor can help you further. Comments SIGNED (required) Please type your name here to signify your acceptance of the above statements. By Submitting this form, you are agreeing for us to contact you. Submit
