Hair Loss Predictor Fact Sheet

• Are you ....
(Check One)…

Male   Female

• I’ve been experiencing hair loss for
(Check One)

Less than 1 year   Less than 3 years   More than 3 years

• Has anyone else in your immediate family, male or female, experienced hair loss?
(Check One)

Yes   No

• Have you ever used FDA-approved drugs such as Minoxidil or Propecia?
(Check One)

Yes   No

• Does your hair loss remain constant (lose about the same amount of hair
week after week) or does it vary (some weeks you lose hair, some you don’t)?
(Check One)

Constant   Varies

• How did you discover you were losing your hair?
(Check One)

Saw hair on your towel, pillowcase, etc.

Noticed bald patches/recession in the mirror

Some one else noticed it and mentioned it to you

•Do you suffer from allergies?
(Check One)

Yes   No

• If yes, what kind of allergies are they?
(Check as Many That Apply)

Food   Air borne (trees, pollen, etc.)   Pet hair   Chemical

• Are you allergic to any types of drugs?
(Check One)

Yes   No

If yes, what kind?

• What, if any, reason do you have for wanting to correct your hair loss problem?
(Check as Many That Apply)

Concerned about appearance

Concerned that hair loss makes you look older

Concerns about effect hair loss can have on job/career

Want to make a fresh start after change in personal relationship or change in job/career status

Suggested by a friend that it would be a good idea

An event or occurrence of some kind lead you to investigate options

Other (Please explain)

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Your name:

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