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Personal & Hair Loss History
Symptoms & Health Info
Treatment History & Goals
Contact & Submission
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What is your Gender:
Male
Female
Other
When did you notice hair loss?
Less than 1 month ago
1–6 months ago
6 months to 1 year ago
Over 1 year ago
Hair loss pattern:
Receding hairline (temples)
Thinning crown
Both crown and hairline
Patchy hair loss
Diffuse thinning (overall)
Complete baldness
Is your hair loss:
Gradual over time
Sudden or rapid
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Scalp Symptoms:
Itching or burning
Redness or rashes
Dandruff/flaking
Painful bumps
None of the above
Medical Conditions:
High or low blood pressure
Prostate-related issues
Mental health conditions (e.g. anxiety, depression)
Trying for a baby / planning pregnancy
Asthma
None
Are you taking any medications or supplements?
Any known allergies or intolerances?
Finasteride
Minoxidil
Lactose
None
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Have you used any treatments before?
Minoxidil (topical)
Finasteride (oral)
Herbal/oil-based
PRP or laser therapy
Never used anything
What is your primary goal from treatment?
Stop further hair loss
Regrow lost hair
Increase density
Maintain current hair
Not sure / Need expert advice
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