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Clinical History

This clinical history takes 5-7 minutes to complete, you can save in case you need to pause.

What is your gender?(Required)
MM slash DD slash YYYY
Where on your head are you experiencing hair loss?(Required)
Where on your head are you experiencing hair loss?(Required)
What type of hair loss have you been experiencing?(Required)
Certain symptoms can indicate less common types of hair loss. Have you experienced any of the following?(Required)

Treatment History

The next few questions will help us understand what treatments have and have not worked for you in the past.

Are you tried any of the following hair loss treatments?(Required)
Do you plan on continuing to use any of these treatments?(Required)

Medical History

The following questions help us understand if there are any underlying medical causes of your hair concerns.

Do you have any of the following medical conditions?(Required)
Do you have any of the following apply to you?
Have you seen a medical professional about your hair loss?(Required)
Have you seen a medical professional about your hair loss?

Have you been diagnosed with any other medical conditions?(Required)
Have you been diagnosed with any other medical conditions?

Have you had any surgeries?(Required)
Have you had any surgeries?

Are you taking any medications?(Required)
Are you taking any medications?
If none, please type 'none.'
Are you pregnant or planning to be pregnant in the next 6 months?(Required)