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Hair Loss Quiz

STARTING YOUR HAIR LOSS CONSULT

This is where it all starts. A few simple questions you’ll answer and you’re on your way. Rest assured, everything is totally confidential.

Please note: this quiz will take approximately 2 minutes to complete.

What is your birth sex?

Male Female

Date of Birth?

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Which of these statements best represents the current status of your hair?

No hair loss Mild receding Medium receding Thinning on crown Thinning + receding No hair on top

How can AdvancedHairDirect help you?

Regrow my hair Prevent further hair loss Regrowth and prevention

How long has your hair been bothering you?

It hasn’t thus far, but better to be ahead of a potential problem Recently For around 6-12 months It’s been thinning/falling out for quite a while, longer than I care to remember I have patches of hair loss I have sudden onset hair loss (really noticeable recently)

Optional: Upload photos to show us where you are experiencing hair loss.

Are you taking any medication, Including prescription or non-prescription medication such as vitamins & supplements?

Please specify

Do you have any allergies?

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Do you have any medical conditions?

Please specify

Are you breastfeeding, pregnant or trying to conceive a baby in the next 6 months?

Have you had any cardiovascular (heart) problems or have you ever had a stroke?

Please provide your contact details so that our Hair Loss Doctor can contact you.

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