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Before we start, what is your name?

We will address you with this name forward

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What is your gender?

Describe who and what

MaleMale
FemaleFemale
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How old are you?

You might have different treatment due to your age

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Are you planning to conceive a child in the next 12 months?

Yes
No
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Is there a history of hair loss in the family?

Yes
No
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Have you had any serious illness before or during?

Yes
No
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Have you been in stress lately?

Yes
No
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Do you have any heart conditions?

Yes
No
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Have you or other family member have prostate issues?

Yes
No
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Do you or family member have any autoimmune disease?

E.g. rheumatoid arthritis, thyroid issues, psoriasis, diabetes, etc.

Yes
No
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What’s the current stage/pattern of hair loss do you have?

Male Pattern 1
Male Pattern 2
Male Pattern 3
Male Pattern 4
Male Pattern 5
Male Pattern 6
Female Pattern 1
Female Pattern 2
Female Pattern 3
Female Pattern 4
Female Pattern 5
Female Pattern 6
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At what point did you start notice it?

Less than a year
1 year ago
2 years ago
3 years ago
4 years ago
5 years ago
More than 5 year ago
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Is it gradual or sudden hair loss that you experience?

Suddenly
Gradually
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Have you experienced hair loss on your face or body?

Yes
No
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Do you have unwanted excessive hair growth on your body?

Yes
No
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Do you have any symptoms on the scalp?

E.g. itching, burning, dandruff, etc.

Yes
No
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How often do you wash your hair?

Once a week
Every few days
Every second days
Every day
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Are you a vegan?

Yes
No
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Have you started any strict diets before or during hair loss?

Yes
No
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Has your weight changed dramatically over the last year?

Yes
No
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Do you take any medications currently?

Yes
No
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Do you have any allergies?

Yes
No
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Have you tried any treatment for hair loss previously?

No, I haven't
Minoxidil 5%
Finastride 1mg
Dutastreid
Combination
Other
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If you’re suitable for Harley treatment plan, would you like a scalp serum or a capsule?

Oral Capsule
Serum
Oral Spray
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Is there anything else you’d like to share?

Please tell us other information you’d like the doctor to know about or any question regarding the treatments

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Where did you heard of us?

Google
Barber / Hairdresser
Instagram
Facebook
Friend
Other
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With this, you confirm to answered the question honestly and to the best of your knowledge.

Yes, I confirm
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What is your email?

We will send your result through this email