To better serve you and increase speed and accuracy we request that you fill
out this form in advance of your meeting with the follicles store manager.

Personal Information

First and Last Name

Address

City

Country

Postal or Zip Code

Home Phone#

Work Phone#

Cell Phone #

Email Address

Preferred Method of Contact?

When

How Did you Hear about us?

Referred by?

PART I: Hair Loss History & Assessment

Date of Birth

When Did your Hair Loss Begin?

What Factors Made Your Hair Loss Worse?

Have you tried any previous hair re-growth methods?

Yes No

If yes, what have you tried?

Do you have any pre-existing conditions?

?Important! Please list any:
Prescriptions, Nutritional Supplements, and Herbal Remedies you are currently taking:

Please list any major:

illness, surgery, accidents, or toxic exposure, and age when this occurred.

Do you have any known allergies or sensitivities to foods, medications or environmental chemicals?	Yes No
If Yes Please List
Do you have any known skin conditions?	Yes No
If Yes Please List
Describe any major past drug use, including marijuana, antibiotics, alcohol, birth control, HRT, Rogaine, Propecia, etc:

?Have any of your blood relatives ever had: (“X” for self, “F” for father, “M” for mother, “S” for sibling, “G” for grandparent.)

Arthritis	High Blood Pressure	Alopecia
Depression	Mental Illness	Other
Diabetes	Thyroid	Other

What level of stress are you experiencing?	? ( 1 = none, 5 = average, 10 = unbearable):
How Many Glasses of Water excluding Tea and Coffee
What time do you go to sleep?
How long do you sleep?
What are the major factors influencing your stress?

Females Only

Are you pregnant?	Yes No
Have you ever given childbirth?	Yes No
If yes, was there an increase of hair loss after childbirth?	Yes No
Which location is closest to you

You can print this form out and bring it with you and/or send it to us electronically, please make sure that you list which store you will be attending.

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