1. How long have you been losing your hair for? (enter # of years)
  Years

2. How severe is your hair loss? (check one)
Light, hard to tell I’m thinning.
Moderate, some scalp is visible.
Somewhat heavy, patches of scalp are visible.
Heavy, much scalp is visible.
Advanced, I have places where I am bald.
Bald with no hair except fringe or less.

3. Where is your hair loss occurring? (check as many as apply)
Overall thinning across the entire top of my scalp.
Thinning in the hairline alone.
Thinning from just behind the hairline to mid-scalp.
Thinning from behind the hairline on back to the crown.
Thinning in just the crown.

4. What type of hair do you have? (check one)
Very fine
Fine
Medium body
Thick

5. What is your scalp condition? (check as many that apply)
Normal
Dry
Oily

6. Do you have problems with your scalp? (check as many that apply)
Dandruff
Sebaceous build-up
Seborrhea
No problems

7. Has your hair loss... ? (check one)
Remained the same over the past year
Increased over the past year
Decreased over the past year