Hair Loss Quiz

What is your gender?

Male

Female

Prefer Not To Answer

What is Your Age?

Under 20

20-30

31-40

41-50

51-60

Over 60

How would you describe the general condition of your hair? *

Check all that apply

Thin

Thick

Dry

Oily

Brittle

Normal

How does your scalp usually feel? *

Check all that apply

Dry

Oily

Flaky

Itchy

Normal

How often do you wash your hair? *

Check all that apply

Daily

Several Times a Week

Once a Week

Less than once a week

Which products do you regularly use? *

Check all that apply

Shampoo

Conditioner

Hair Masks

Oils

Styling Products

Natural or Organic Products

How often do you use heat on your hair? *

Frequently (several times a week)

Occasionally (once or twice a month)

Rarely

Never

What is your protein intake like? *

High (meats, dairy, legumes, etc)

Moderate

Low

Do you actively take vitamins or supplements for hair health (Vitamins D, B-Complex, Biotin, or Iron) *

Yes

No

Not sure

How often do you exercise ? *

Daily

Several times a week

Weekly

Rarely

Never

How would you describe your stress level? *

High

Moderate

Low

Very Low

Does anyone in your family have a history of hair loss?

Yes

No

Do you have any underlying health conditions? *

Thyroid Disorder

Hormonal Disorder

Autoimmune Diseases

Other

None

Are you currently on any medications

Yes

No