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

Which of the following best describes your goals with reversing your hair loss? (Select ALL that apply)

A) I want to wake up happy knowing my hair is growing back
B)I’d like to enjoy photos instead of hiding from the camera
C) I want to look younger and full of energy in the mirror
D) I can’t wait to hear people say, “Your hair looks great—what did you do?”

What makes you interested in this new breakthrough treatment specifically though? Why is it compelling compared to other options to regrow your hair? (Select ALL that apply)

A) Because it’s non-surgical, yet can get transplant level results.
B) It can be completed in just a single session, lasting only 60-minutes
C) I want to leverage brand new hair restoration technology. Backed by a 100% performance guarantee.
D) Because it’s already helping 7,000+ patients regrow their hair!

Do you have a history of active cancer in the last 5 years?

Yes
No

Are you completely bald? Or do you currently have hair?

I have hair
I am completely bald

Which of the following best describes your current hair loss in the affected areas?

Why is putting an end to your hair loss, a priority for you right now?

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

How much do you budget for your wellness each year?

Less than $1000
More than $1000. Less than $10,000
More than $10,000

We know this question may feel personal—but it's important. It helps us prioritize patients who are committed to long-term results, and tailor recommendations that make sense financially and medically.

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

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