2803 W Butterfield Rd.
Oak Brook, IL 60523
(630) 572-3700
Fax: (630) 572-9960

18015 Torrence Ave.
Lansing, IL 60438
(708) 474-7400
Fax: (708) 474-7402

DETROIT OFFICE
3044 Telegraph RD.
Suite 113
Bingham Farms, MI. 48025
(248)540-0900
FAX (248) 540-0523

 

HAIR LOST CONSULTATION

The diagrams below have been designed to identify the pattem of hair loss as the percentage of hair loss. Different pattems and percentages are treated differently by a trichologist. Please fill in the questionnaire and select what picture best describes the percent of hair loss your are currently experiencing.

CONFIDENTIAL
HAIR ANALYSIS QUESTIONNAIRE

I.- General
Name Birthdate: Age
Address:
City: State Zip
Phone-Home E-mail
II.- History
1.- Hair Condition: Dry Oily Breaking Falling
2.- Scalp condition Dry Oily Scaling: Small
Large Reddish areas Burning sensation Itching sensantion
All the time Periodic: how ofthen ?
3.- Hair Density in remaning areas: Medium Thin
4.- Hair Texture: Average Fine
5.- Hair Texture: Curly Wavy Straight
6.- Skin Complexion: Medium Light
7.- Do you have any skin allegiers? Yes No, If yes, List them
8.- Have you ever been treated by a dermatologist for skin or scalp?
Y es No
9.- Have you had any major illnmes or have undergone surgery up tp 3 years before you hair loss began? Yes No , If yes, what?
10.- Have you ever had scalp disease? Yes No
11.- At what age did you first notice that you were losing your hair?
12.- Is baldness hereditary in your family? Father Mother
Grandfather Grandmother

13.- Would you say taht you are losing your hair: Rapidly Slowly
Stopped

14.- Have you ever noticed any drandruff during period of hair loss? None A little Excessive
15.-Select the level baldness according to the graphic.
A B C D E F G H I J

Our hair loss specialist will answer your questionnaire via  e-mail".If you want us to call you to review your question in detail, fill in  the "Contact Us" page in the next section.