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Hair Loss Questionaire

Let me start off by saying that I understand how personal all these questions and your answers are.  I want you to rest assured that they are for my eyes only and will not be shared with anyone.  Your answers to these questions will help me determine what type of hair loss you may be experiencing.  It will also help me determine what type of treatment and homecare products are needed to help either slow down your genetic hair loss or help grow back hair lost from stress, illness or nutrition issues. 

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If it is within my normal business hours, I will respond in 12-24 hours.  

Hair Loss Questionnaire

Are you currently following a diet?
Has your hair loss been sudden or gradual?
Sudden
Gradual
Are you experiencing any of the following scalp issues? Select all that apply.
Does hair loss run in your family?
Yes
No
Not sure
Have you been diagnosed with Alopecia Areata (AA)?
Yes
No
Do you smoke or vape?
Yes
No
Are you currently taking prescribed medication?
Yes
No
What is your current stress level?
1
2
3
4
5
Other

Disclaimer

I understand that during my initial evaluation and recheck appointment, microscopic photos will be taken of my scalp.

I understand these photos maybe used for social media purposes with blurred out faces.

I understand that it is my responsibility to follow up with my physician before starting any new supplements.

I also understand that Marisa's recommendations should not be substituted for medical advice by a physician.

By consenting to these terms, I further understand that results will vary depending on a large number of factors.

I acknowledge that it is my responsibility to advise Marisa of any changes in my condition, no matter how slight.

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