Form For Women @ American Image

For Women: Free Hair Loss Evaluation from American Image.

Where has the hairloss occured? *

ABCDE

How long have you been losing your hair *

Is the scalp visible in the area where you have lost your hair? *

YesNo

Do you suffer from... *

nonedandruffitchy scalpoily scalpdry scalp

Would you characterize your existing hair as... *

Is the hair growing on the sides of your head? *

Does your scalp excrete excessive sebum (oils)? *

YesNo

Have you ever experienced a build-up of sebum (oil) on your scalp? *

YesNo

Does your scalp ever flake? *

YesNo

Do you ever see red blotches on your scalp? *

YesNo

How would you rate your current rate of hair loss? *

Have you experienced an increase in your rate of hair loss in the past year? *

YesNo

Have you ever tried to do anything about your hairloss? *

Hair ReplacementLotions/ShampoosHair TransplantOral MedicationsLasersRogaineNothing

Have you ever seen a doctor about your hair loss? *

YesNo

Has anyone ever mentioned your hairloss to you? *

BoyfriendFriendsCo-WorkersMotherFatherGirlfriendOtherStrangersHusbandWife

Does that bother you? *

Why do you want to do anything about your hair? *

For employment or job opportunityI hate the way my hair looksI look older than I feelPeople make fun of meI want to meet younger men/women

Do you want to: *

Have more hair?Stop your hairloss?

How did you hear about us? *

First Name: *

Last Name: *

Street Address *

Apt, Suite, Bldg

City *

State *

Postal Code *

Age *

Email *

Phone *

Additional Comments?