What’s your natural hair type?
Straight
Wavy
Curly
Coily
How do you typically style your hair?
Heated tools
Color treatments
Protective styles
Chemical processing
None
How often do you wash your hair?
Daily
Few times/week
Weekly
Few times/month
What changes are you noticing in your hair?
Thinning
Shedding
Widening part
None
Are you experiencing any of these symptoms?
More scalp showing
Hair in brush
Shedding in shower
Thinner ponytail
Breakage
When did you first notice changes?
Over a year ago
Past year
Past few months
Not sure
How quickly did the changes happen?
Suddenly
Gradually
Not sure
What are your hair goals?
Reduce shedding
Improve fullness
Regrow hair
Support hair health
Confidence
Which treatments have you tried?
Rx
OTC serum
Vitamins
Shampoo/conditioner
Something else
None yet
How would you feel about doctor-trusted prescription treatments?
Ready to start
Want info
Unsure
Select your age range
18–29
30–39
40–49
50+
Do you have a family history of thinning hair?
Yes
No
Not sure
How frequently do you feel stressed?
Never
Always (5-point scale)
Major stressful event recently?
Yes
No
Current diet?
Meat eater
Vegetarian
Vegan
Other
Water intake per day?
1–2
3–7
8+ glasses
Name
*
Email Address
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Date
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