Non-surgical Hair Restoration Questionnaire

Hair Loss History:

How long have you been experiencing hair loss?

Less than 6 months
6 months to 1 year
1 to 2 years
More than 2 years

What areas of your scalp are most affected by hair loss?

Check all that apply

Have you tried any treatments for hair loss before?

Yes
No

which treatments have you tried?

Topical treatments (e.g., minoxidil)
Oral medications (e.g., finasteride)
Over-the-counter products (e.g., shampoos, supplements)
Hair transplant surgery
Other

Check all that apply

Please specify

Current Hair Care Routine:

How often do you wash your hair?

Daily
Every other day
Twice a week
Weekly

What types of hair care products do you currently use?

Check all that apply

Please specify

Lifestyle and Health:

Do you have any underlying health conditions?

Yes
No

(e.g., thyroid issues, hormonal imbalances

Please specify

Do you take any medications regularly?

Yes
No

Please specify

Do you smoke?

Yes
No

Do you consume alcohol?

Yes
No

How would you describe your diet?

Balanced and healthy
Moderately healthy
Unhealthy

Unhealthy Interest in Non-Surgical Solutions:

How familiar are you with PRP (Platelet-Rich Plasma) therapy for hair loss?

Very familiar
Somewhat familiar
Not familiar

How familiar are you with Exosome therapy for hair loss?

Very familiar
Very familiar
Not familiar

What interests you about non-surgical hair loss treatments?

Check all that apply

Please specify

Are you interested in scheduling a consultation to discuss your hair loss and potential treatment options?

Yes
No

Please indicate your preferred days and times for a consultation:

Date

Time

Additional Comments:

Please share any additional comments or concerns you have about your hair loss or potential treatments:

Are you interested in proactive healthcare and preventative measures to optimize your health and longevity?

Yes
No

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Yes
No

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Yes
No

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations