Name
	Phone
	Email
	Address
	City
	State
	ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY
	Zip Code
	Current Age?
	Age your started losing hair?
	How much hair did you lose daily?
	Under 20 Between 20 - 50 Over 50
	Indicate your current state of baldness by checking the one illustration below that most resembles your hair loss condition.
	A B C D E
	Regarding the illustration you checked above, how long have you looked like this? (number of years)
	What is the texture of your hair?
	Thick, curly Thick, straight Thin, curly Thin, straight
	Do you suffer from any allergies?
	Yes No
	Are you currently taking any kind of medication?
	Yes No
	If so (taking medication), please list them?
	Has anyone in your family experienced hair loss? (check all that apply)
	Mother Father Aunt Uncle Sibling(s)
	Has the average number of hair you lose per day increased in the past three years?
	Yes No
	Additional comments
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