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My Hair Growth Clinic

Consultation Questionnaire

Birthday
Month
Day
Year

Personal History

Do you have any of the following issues? (check all that apply)

Females only:

Do you have Female Issues?
Yes
No
Postmenopausal?
Yes
No
Pregnant or Breastfeeding?
Yes
No

Males Only

Have you currently had or plan to take a PSA blood test for the screening of prostate cancer?
Yes
No
Do you have an enlarged prostate or prostate cancer?
Yes
No


Hair & Scalp Conditions

My scalp is usually: (check all that apply)
Do you pull on your hair?
Yes
No
Areas of thinning or hair loss:
Do you have hair of different lengths? (other than your layers)
Yes
No
Any hair loss on body?
Yes
No
Your thinning/hair loss was:
If you use a hair dyer, what heat do you use it at?
Who in your family has had hair loss or thinning?
How much does your hair loss/thinning bother you?
What are your goals and expectations?
Knowing that treatment options may take 6 months to show success, are you willing to wait that long?
Yes
No

Consent for Treatment

I agree to be evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experience consultant. All other check ups are included with the programs cost, which includes monthly and or quarterly digital and microscopic pictures, for which I give my consent. I further understand results will vary depending on a large number of factors. I acknowledge that it is my responsibility to the company for any changes in my condition no matter how slight. 

Date
Month
Day
Year
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