
Call us at 425-774-2007 or Toll Free at 800-771-1540

Free Hair Loss Evaluation from American Image

1. Are you Male or Female?
Male Female

2. How long have you been losing your hair?
1-3 years 3-7 years 7-15 years more than 15 years

3. Where has the hairloss occured?
(A) (B) (C) (D) (E)

4. Is the scalp visible in the area where you have lost your hair?
Yes No

5. Do you suffer from...? (choose as many as applicable)
dandruff itchy scalp dry scalp oily scalp

6. Would you characterize your existing hair as... (choose one)
Dry Oily Normal

7. Is the hair growing on the sides of your head? (choose one)
thin and full thick and full thin and slightly receding

8. Does your scalp excrete excessive sebum (oils)?
Yes No

9. Have you ever experienced a build-up of sebum (oil) on your scalp?
Yes No

10. Does your scalp ever flake?
Yes No

11. Do you ever see red blotches on your scalp?
Yes No

12. How would you rate your current rate of hair loss? (choose one)
light moderate Heavy

13. Have you experienced an increase in your rate of hair loss in the past year?
Yes No

14. Have you ever tried to do anything about your hairloss?
Rogaine Hair Transplant Hair Replacement Lotions/Shampoos Nothing

15. Have you ever seen a doctor about your hair loss?
Yes No

16. Has anyone ever mentioned your hairloss to you?
Wife Girlfriend Husband Boyfriend Mother Father Other

17. Does that bother you?
Yes No

18. Why do you want to do anything about your hair?
I look older than I feel I hate the way my hair looks I want to meet younger men/women
For employment or job opportunity People make fun of me

19. Do you want to:
Stop your hairloss? Have more hair?

Additional Comments?

20. How did you hear about us?

First Name:
Last Name:
Address:
City:
State:
Zip:
Region:
EMail:
Phone:
Age:

When you are ready to submit the above information just click on the button below.
Once submitted you will be returned to the home page.