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?
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Yes
No
2. How old are you?
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Less than 21
21 to 45
45 to 55
55+
3. How long have you been losing hair or thinning?
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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?
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Yes
No
5. Do you have any medical conditions that require you to be under a doctors care?
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Yes
No
6. Do you take any prescribed medications that require a doctors prescription?
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Yes
No
7. How much weight have you lost in the past 12 months?
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10 to 20 lbs
20 to 35 lbs
35 to 50 lbs
50+ lbs
8. Is your Weight Loss program supervised by a physician?
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Yes
No
9. How would you rate your stress levels?
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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?
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Yes
No
First name
*
Last Name
*
Email
*
Phone
*
Please describe your hair loss issue
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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.
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YES, I wish to receive a call from the Hair Loss Specialist to discuss my results.
Best Time To Call 📞
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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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