Book Now Get More Hair – Get More Life! ® Get More Hair – Get More Life! ® This questionnaire supplies your consultant with helpful information which will aid in a better understanding of your hair and scalp structure. The more complete the information, the more accurate the services. Please read each question carefully. Answer every question by checking the appropriate statement which is most correct for you. Some questions may require write-in answers. Please answer completely. If you are in doubt, please ask for assistance. Name * First Last * Last Email * Phone Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Birthdate Gender Female Male Occupation Relationship Status Single Engaged Married Divorced Seperated Widowed How did you hear about us? Referral TV Radio Newspaper Mailings Magazine Internet Social Media Google Yelp OtherOther Which TV Channel? Which Radio Station? Which Mailing? How old were you when you first noticed hair loss? Did your hair loss develop... Slowly Rapidly Please detail any hair loss in other members of your family: Family History of hair loss or baldness if applicable? Mother's Side Father's Side Neither Not sure? Medical History At your last doctor’s appointment, were any hair, scalp or medical problems diagnosed? Yes No Can you recall being ill and / or under stress prior to your hair loss problem? Yes No Are you aware of any scalp conditions you may have? Dandruff Flaking Itching Breakage OtherOther To your knowledge, do you currently have a scalp disorder (example- alopecia )? Yes No Are you aware of any open sores or abrasions on your scalp? Yes No Are you presently taking any medications? Yes No Do you have any allergies that you are aware of? Yes No Have you ever been treated for a hair and/or scalp problem? Yes No Please select any of the following you have tried in the past. Rogaine Propecia Hair Replacement Hair Transplant PRP (Plasma Rich Platelets) Laser Therapy OtherOther Do you or anyone in your family have a history of Thyroid disease? Yes No Have you ever been diagnosed with PCOS (Polycistic ovary syndrome)? Yes No When is the last time you had a CBS (complete blood count) blood test performed? Daily Maintenance: How often do you shampoo? (times per week) What brand of shampoo are you currently using? Do you use a conditioner? Yes No Have you ever colored or permed your hair? Yes No Lifestyle: Please indicate in which areas of your life that hair loss is affecting you: (please check all that apply) Meeting new people Your self esteem When others make comments On a windy day At the beach or swimming In your social life Seeing old friends Your overall appearance When you get dressed-up At work When having to wear a hat When playing sports OtherOther Please check one or all that apply. I want to stop my hair loss. I want to fill in the area I have hair loss. I want to have a full, normal head of hair. I want to just check Hair Restoration Institute out. If you have been advised by other professionals, please select one or all that apply to as why you have chosen us. Dissatisfaction with the previous advice or results Reputation and experience Location OtherOther Salon that you currently go to: City it is located in: Do you need someone other than yourself to make the decision to correct your hair loss problem today? Yes No Knowing that some of our treatment plans may take up to one year to reap the full fruition of the treatment, are you willing to wait that long for the final result? Yes No At this time, are you financially able to do something about your hair loss? Yes No What day and times work best for you to schedule a 30 minute virtual consultation? Additional Information you would like us to know: I attest that the above information is accurate and that I have fully answered all of the above questions to the best of my ability. * Yes No Today's Date Attach an Image Drop a file here or click to upload Choose File Maximum upload size: 2.1MB Please check the box Submit
