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Hair Loss Shop
Derma Rollers & Stamps
Hair Fibres
Hair Loss Medication
Shampoo and Conditioner
Topical Hair Loss Treatments
Vitamins and Supplements
Shop By Gender
Treatments for Female
Male
Shop All
Services
Hair Transplants
Beard Transplant
Hair Transplant for Women
Eyebrow Transplants
Hair Treatments
How to STOP hair loss
Topical Hair Loss Treatments
Hair Loss Medication
Hair Loss Prevention Treatments
Pharma Hermetic Hair Recovery Program
About
Blog
Contact
Menu
Hair Loss Shop
Derma Rollers & Stamps
Hair Fibres
Hair Loss Medication
Shampoo and Conditioner
Topical Hair Loss Treatments
Vitamins and Supplements
Shop By Gender
Treatments for Female
Male
Shop All
Services
Hair Transplants
Beard Transplant
Hair Transplant for Women
Eyebrow Transplants
Hair Treatments
How to STOP hair loss
Topical Hair Loss Treatments
Hair Loss Medication
Hair Loss Prevention Treatments
Pharma Hermetic Hair Recovery Program
About
Blog
Contact
Medical Questionnaire
Hair Repair MQ
1
Step 1
2
Step 2
3
Step 3
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Occupation
(Required)
Address
Street Address
City
County / State / Region
ZIP / Postal Code
About You
A few questions about your health and lifestyle
If you are a smoker how many cigarettes do you smoke each week
How many units of alcohol per week
When did you first notice you were losing hair?
(Required)
Does anyone in your family suffer from hair loss?
(Required)
Does anyone in your family suffer from hair loss?
Yes
No
Unknown
What side of the family?
(Required)
Fathers Side
Mothers Side
Fathers and Mothers Side
Have you been diagnosed with Androgenic Alopecia (Male/Female Pattern Baldness)?
(Required)
Yes, by my GP
Yes, by a specialist
No, self-diagnosed
Have you tried any hair loss treatments before?
(Required)
Yes
No
Please list any treatments
(Required)
For example: Finasteride, Propecia, Dutasteride, Minoxidil, Supplements
Have you had any previous hair loss procedures?
(Required)
Yes
No
Please provide details of previous procedures
(Required)
Are you currently taking any other medication, or have you recently finished a course of medication?
(Required)
Yes
No
Please provide details of any other medication you are taking or have recently finshed
(Required)
Are you allergic to any medicines or other substances?
(Required)
Yes
No
Please list any allergies
Do you have any skin conditions?
(Required)
Yes
No
Please provide details of any skin conditions
For example: Keloids, Seborrheic Eczema, Dermatitis, Psoriasis etc
Please provide us with pictures of your hair to aid us with your assessment
Front View
(Required)
Max. file size: 64 MB.
Side View
Max. file size: 64 MB.
Back View
Max. file size: 64 MB.
Top of Head View
Max. file size: 64 MB.
Consent
(Required)
I fully understand the questions asked and have answered honestly and truthfully.
