Weight Loss

Hair Loss Assessment

9 Out of 10 People

Who Take This HAIR LOSS ASSESSMENT

Find The Solution To Their Hair Loss!

1. Were you experiencing hair loss prior to you losing weight?*
- Yes
- No
2. How old are you?*
- Less than 21
- 21 to 45
- 45 to 55
- 55+
3. How long have you been losing hair or thinning?*
- Less than 1 year
- 2 to 5 years
- 5 to 10 years
- 10+ years
4. Does anyone else in your family suffer from hair loss or thinning hair?*
- Yes
- No
5. Do you have any medical conditions that require you to be under a doctors care?*
- Yes
- No
6. Do you take any prescribed medications that require a doctors prescription?*
- Yes
- No
7. How much weight have you lost in the past 12 months?*
- 10 to 20 lbs
- 20 to 35 lbs
- 35 to 50 lbs
- 50+ lbs
8. Is your Weight Loss program supervised by a physician?*
- Yes
- No
9. How would you rate your stress levels?*
- Average
- More than Average
- Very High
- Severe
10. Have you suffered any life altering events that can be classified as “traumatic” in the past 5 years?*
- Yes
- No
First name*
Last Name*
Email*
Phone*
Please describe your hair loss issue*
Before we begin your Hair Loss Assessment, please check the box below acknowledging that in order to protect your Privacy the results of your assessment WILL NOT be shared through Email or Text.*
- YES, I wish to receive a call from the Hair Loss Specialist to discuss my results.
Best Time To Call 📞*
- Morning
- Afternoon
- Eveninig
*Disclaimer: This is a general and preliminary assessment. An In-person Consultation and Scalp examination is necessary for a full treatment recommendation.
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hair loss assessment

Take A 30-Second Hair Loss Assessment

Answer 10 Simple Questions And Find The Causes Of Your Hair Loss!

These questions are designed to help identify some of the more common triggers associated with hair loss. Providing us with this information is an important step in finding the right hair loss solution for you.

Start My Assessment