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Friend Google Magazine MSN News Other Search Engine Other Salon / Spa Professional Word of Mouth Yahoo Privacy is necessary Yes No Age: Age at onset of hair loss How fast does hair loss currently seem to be progressing? Medications taken for hair loss (please give dates and effectiveness): Rogaine (minoxidil) 2% Rogaine (minoxidil) 5% Minoxidil plus Retin-A Propecia (finasteride) 1mg Proscar (finasteride) 5mg Other Check Which Members of Family Have/Had Significant Hair Loss Father Mother Brother(s) Paternal Uncle Maternal Uncle Paternal Grandfather Maternal Grandfather Other Indicate Your Current Hair Condition: Hairline Normal Thinning Very Thin Bald Frontal Recession Normal Thinning Very Thin Bald Frontal Area Normal Thinning Very Thin Bald Mid Scalp Normal Thinning Very Thin Bald Using the following diagrams, Indicate Your Current Hair Loss Pattern and the Hair Loss Pattern You Believe You May Progress To in the Future: Men, please complete this first Hair Loss Pattern Chart. Women, please complete the one below Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Women, please complete the following Hair Loss Pattern Chart. The Men's chart is above. Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Indicate All the Characteristics of Your Hair: Hair Color Black Brown Gray Blonde Red Salt & Pepper Hair Curl Straight Slightly Wavy Wavy Curly Hair Thickness Fine Medium Medium Coarse Coarse Past Hair Surgery History (dates, physician/clinic, graft number): Please Describe Your Goals for Hair Restoration: In-Depth Consult Talking to Patients Meeting Patients Viewing a Procedure Frontal: Top: Side: Back: * I accept the Terms of Use * Phone This field is for validation purposes and should be left unchanged.
