• 1How long ago did you first notice any signs of hair loss?
  • 2What symptoms of hair loss have you noticed?
  • 3What treatments have you already tried?
  • 4Do other people in your family have hair loss?
  • 5Do you have any issues with sexual dysfunction currently?
  • 6Do you have any medical conditions?
  • 7Have you ever had any surgeries or hospitalizations?
  • 8Do you currently take any medicines, herbals, or supplements?
  • 9Do you have any allergies or medication reactions?
  • 10Do you have any concerns about your mood, depression, anxiety, or worrying?
  • 11Do any of the following currently apply to you?
  • 12Have you ever had any of the following medical conditions?
  • 13This photo must have be taken in the last 30 days

    How long ago did you first notice any signs of hair loss? *

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