1. Current age 2. Age you started losing your hair 3. How much hair do you lose a day? (choose one): 20 hairs 20-50 hairs over 50 hairs 4. Indicate your current state of baldness by checking the one illustration below that most resembles your hair loss condition. ( A) (B) (C) 5. Regarding the illustration you checked above, how long have you looked like this? (number of years) 6. Regarding the chart above, how long ago was it that you more closely resembled the illustration to the left of the one you selected? (number of years) 7. What is the texture of your hair? Thick, curly Thick, straight Thin, curly Thin, straight 8. Has the average number of hair you lose per day increased in the past three years? Yes No * First Name * Last Name * Email Address City State Zip Phone Message
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