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Do you suffer from...? (Select as many as applicable)DandruffItchy ScalpDry ScalpOily Scalp
How long have you been losing your hair?1-3 years3-7 years7-15 yearsmore than 15 years
Would you characterize your existing hair as...DryOilyNormal
Is the hair growing on the sides of your head?Thin and fullThick and fullThin and slightly receding
Does your scalp excrete excessive sebum (oils)?YesNo
Have you ever experienced a build-up of sebum (oil) on your scalp?YesNo
Does your scalp ever flake?YesNo
Do you ever see red blotches on your scalp?YesNo
How would you rate your current rate of hair loss?LightModerateHeavy
Have you experienced an increase in your rate of hairloss in the past year?YesNo
Have you ever tried to do anything about your hair loss?RogaineHair TransplantHair ReplacementLotions/ShampooNothing
Have you ever seen a doctor about your hairloss?YesNo
Has anyone ever metioned your hairloss to you?WifeGirlfriendHusbandBoyfriendMotherFatherOtherNo
Does that bother you?YesNo
Why do you want to do anything about your hair?I look older than I feelI hate the way my hair looksI want to meet younger men/womenPeople make fun of me
Do you want toStop the hairloss?Have more hair?
136 36th St Dr SE Ste A-5
Cedar Rapids, IA 52403