Age?

Gender

Approximately, how many hair strands do you lose in a day?

How many of the following symptoms do you relate to?

Which of the following lifestyle habits do you have?

Select all the medical conditions that apply:

Are you currently undergoing any of the following treatments?

Are you currently engaged in any of the following alternative therapies?

Which of the following aesthetic activities do you engage in?

Is there a history of balding in your family line?

Are you pregnant or undergoing menopause?

Choose the closest stage of hair volume you can relate to:

Choose the closest stage of hair volume you can relate to:

Please list any other conditions or treatments that are relevant to you.

score

40
  •  Mild
  •  
  •  Moderate
  •  Severe

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