Answer the following questions to tell us more about your hair loss condition.
For some questions, please check YES or NO in the box at the right. For other questions, please write your answers in the space provided.
Your Information
Hair Loss Background
Please check the box that best describes your family members’ scalp hair (If you have more than one brother or sister, mark the box that describes the brother or sister who has the least amount of hair):
Health Information
For Females
Lifestyle Information