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Hair Loss Online Consultation

This is a quick 3 minute validated questionnaire to identify and help both men and women who have a problem with Hair Loss.
Treatments are available to help you with this condition.

These Online Tests are simple questionnaires that are submitted to our Doctors to see if Face Doctors has a solution that is right for you. They are obligation free and absolutely confidential. Our Doctors will respond within 24 hours to your submission from your given email address.

Please note this treatment is only available at our Remuera Clinic.

* Indicates required field

How did you hear about this site? *

Internet Search Advertisement Radio Advertisement Digital or Newspaper Friend Other

If Other please specify: *

Name *

First

Last

Age *

Gender *

Male Female Other

If Other Please Explain *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

When did you start losing your hair? *

Has it worsened recently? Yes or no. *

Is your hair loss *

Diffuse Thinning Scattered Patchy Other

Please Explain: *

Do you have a family history of hair loss? *

Yes No

If so, who: *

Which hair loss type do you have? Male Norwood Scale. Female Ludwig Scale. See bottom of page. *

Describe your general health. *

Good Average Poor

please explain in more depth: *

Serious illness past few years? Please describe. Type Nil if none. *

Past Medical History. Have you had any of the following? *

Anaemia. Iron Deficiency Autoimmune Disorder Arthritis Inflammatory Bowel Disease Diabetes Thyroid Disease Over and Underactive Kidney Disease Liver Disease Cancer Radiation or Chemotherapy Mental Illness Depression Emotional Stress or Anxiety Hair Transplant Previous Treatment for Hair Loss Post Pregnancy SkinInfections Fungal Bacterial Viral Chronic HSV Significant Illness or Disease Significant Trauma Significant Surgery Significant Weight Loss Other None of these

Please explain further if you have clicked any of the above. *

Do any of the following apply? *

Post Pregnancy Trouble with Acne, Oily Skin Growth of Facial and Body Hair On Oral Contraception NONE OF THESE

If you clicked any of the above, please explain. Please advise what contraception you are on. *

List all current medications. Type Nil if none. *

List medicines when hair started falling out. For example antihistamines, cholesterol meds. Type Nil if none. *

Allergies to medicines or other. Type Nil if none. *

Dietary considerations. Tick any that apply. *

Vegetarian / Vegan High Processed Carb Intake High GI Food Intake Dieting Recently Iron Deficiency High Vitamin A intake High Whey Protein Intake Testosterone Booster or Analogues None of These

Please explain further if you have ticked any above. *

Are you taking Vitamins, Herbal medicines or performance enhancing drugs, steroids? Type Nil if none. *

Do you exercise? *

Yes No

If yes, how many times a week. *

Do you smoke? *

Yes No

If yes. How many per day and for how long. *

What do you use to clean your hair? *

How often do you shampoo your hair per week? *

How often is your hair chemically processed or straightened? Type Nil if none. *

Are there any treatments that are of interest to you? *

Newsletter sign up *

By submitting this form you will be signed up to the Face Doctors Clinic Newsletter. We respect your privacy and you can unsubscribe at anytime.

Submit

Norwood Classification Scale

Ludwig Classification Scale

Your personal details will remain confidential and not disclosed to any third parties. You have the right to view, change or delete this information on request. This questionnaire is not comprehensive, and does not replace a full history and physical examination and further information may be necessary on follow-up. Due diligence will be exercised for making a thorough assessment.

Book For Auckland Clinics

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Auckland Choose Location *

Remuera Howick Manukau Head Office (No Clinic)

Ideal date and time *

Treatments Required *

Or email [email protected]

Submit

Book For Northland Clinics

* Indicates required field

Name *

First

Last

Email *

Phone Number *

NORTHLAND CHOOSE LOCATION *

Warkworth Marsden Cove Whangarei Kerikeri Doubtless Bay

IDEAL DATE AND TIME *

TREATMENTS REQUIRED *

Or email [email protected]

Submit

Please note this does not confirm your booking. We will get in touch with you to confirm your appointment time.
By submitting this form you will be signed up to the Face Doctors Clinic Newsletter. We respect your privacy and you can unsubscribe at anytime.
Please note we have allocated client parking, all unauthorized vehicles may be clamped or towed at owners expense. Clamping proceeds will be donated to monthly charity of our choice.

Face Doctors. Sign up to our Education & New Treatment Protocol Newsletter

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Name *

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Last

Email *

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Hair Loss Online Consultation

Book For Auckland Clinics​

Book For Northland Clinics

Face Doctors. Sign up to our Education & New Treatment Protocol Newsletter​

Book For Auckland Clinics

Face Doctors. Sign up to our Education & New Treatment Protocol Newsletter