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Women's Hair Test

3. YOUR INFORMATION

Age:




Length of time since hair loss/thinning began:



Other products and procedures I have tried for hair loss
(choose any that apply):
None       Used other non-drug product in the past
Using a Minoxidil Product Using non-drug hair loss product
Using Propecia Used Minoxidil in the past
Using a Minoxidil product and Propecia Used both a Minoxidil and Propecia in the past
Using other hair loss drug or other combination of hair loss drugs Transplant



If you have used a product other than minoxidil or propecia please tell us what it was.



What do you think or have been told is causing your loss/thinning
(choose any that apply):
Other family members have hair loss/baldness       Chemotherapy or radiation therapy
Stress Following pregnancy/childbirth
Prescription drugs I am using or have used Menopause
Surgery Hormonal imbalance
Damaged hair related to perm, coloring, etc. Birth control pill or hormonal therapy
Diet



Attitude towards using products that contain drugs (such as minoxidil or Propecia):



Other hair/scalp problems you are having
(choose all that apply):
Flaky scalp       Dermatitis       Seeing a doctor for scalp condition
Oily hair/scalp Seborrhea Hard to keep hair clean
Eczema Chemical damage to hair Brittle or easily breakable hair



Reason(s) current hair loss/thinning or possible future loss/thinning bothers me
(choose all that apply):
I feel less confident       It has a negative effect on my job
I feel less attractive I'm treated differently by other people
It is embarrassing I worry about it getting worse
It makes me look or feel older Not concerned enough to do anything about it
It has negative effects on my love life It has a negative effect on my ability to get a job
I don't want to end up bald

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