2440 M Street, NW. Suite 205 • Washington, D.C., 20037
• 202-785-3175
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prefer to be contacted by:
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Please send me a "FREE"
Hair loss Evaluation
1.
Age:
Sex:
2.
What color is you hair?
Black / Dark Brown
Gray
Med Brown
Light Brown / Blond / Red
3.
Which characteristic best describes your natural hair?
straight
wavy
curly
4.
What is the texture of your hair?
fine
medium
thick
5.
Click on the image that best depicts your hair loss condition when
your hair is wet.
6.
At what age did you notice hair loss?
< 20
21-30
31-40
41-50
50 >
7.
Has your hair loss or thinning increased significantly in the past
five years?
Yes
No
8.
Is your hairline receding at the temples?
Yes
No
9.
Are you developing a bald spot that's visible from behind?
Yes
No
10.
Are you experiencing hair loss on the top of your head?
Yes
No
If
you answered yes to the previous question, proceed to question
11.
If you answered no, skip ahead to question 16.
11.
Are you able to see a lot of skin through your hair when your hair
is dry?
When
your hair is wet?
Yes
Yes
No
No
12.
Are you able to see a well-defined horseshoe shaped pattern of baldness
on you head when your hair is dry?
When
your hair is wet?
Yes
Yes
No
No
13.
Is the texture of the hair on top of your head finer or frizzier than
the hair on the sides and back of your head?
Yes
No
14.
Have you noticed that the hair on the sides and back of your head
needs to be cut more frequently than the hair on the top of you head?
Yes
No
15.
What area of your scalp are you most interested in having treated?
Front Only
Back Only
Top Only
Entire Balding Area
16.
Have you consulted with a doctor about your hair loss condition?
With
Whom?
Yes
No
17.
What treatment, if any, was recommended?
18.
Have you ever had surgical hair restoration performed?
Yes
No
19.
Have you treated your hair loss with any of the following?
Rogaine
Past
Present
Saw
Palmetto
Past
Present
Propecia
Past
Present
Other
Past
Present
20.
Please rank the concerns that apply to your feelings about hair restoration
surgery in order of importance to you (1 = your greatest concern)
Camouflaging after surgery
Affordability
Discomfort
Final result
Time off work
Other
You
may email photos of your head
(with wet hair) taken at four angles - front view, back view, top
view (looking at the ground), and 45ƒ angle (head turned to show hair
loss at the temple.)
Please Email me notices of new developments and special offers as
they become available
