Free Hair Loss Evaluation

First and Last Name (required)

Phone Number (required)

Email Address

Address

City

State
---NJNYPACTMADEMDVA

Zip Code

How Would You Like To Be Contacted?
 Phone Email Postal

Would you like to enter our quarterly drawing for a FREE Abstrax treatment program for one year?
 Yes No

Your Age
---18-2021-2526-3031-4041-5051-6061-7071-80

Gender
 Male Female

Ethnicity/ Hair Type
---White/ CaucasianAfro/ CarribeanIndianAsianArab

What Best Describes Your Hair Loss Condition?
---Male Pattern BaldnessFemale Pattern BaldnessThinning HairReceding HairlineMedical Condition RelatedAlopecia TotalisAlopecia AreataAlopecia UniversalisChemotherapy RelatedNot Sure

How long have you been experiencing hair loss?
 1-3 Years 4-7 Years 7-15 Years

Is your scalp visible in the area where you have lost your hair?
 Yes No

Do you suffer from any of the following conditions?
 Dandruff Itchy Scalp Dry Scalp Oily Scalp Excessive Shedding

Have you attempted to do anything about your hair loss situation?
 Rogaine/Propecia Hair Transplant Herbal Solution Hair Extensions Hair Systems Lotions/Shampoos Nothing

Have you consulted a doctor or other professional about your hair loss?
 Yes No

How often do you think about your hair loss situation?
 Not Much Sometimes All The Time

Does your hair loss situation ever make you feel depressed?
 Yes No

Do you feel that your hair loss prohibits you from being "who you really are"?
 Yes No

Do you feel that your hair loss adversely affects your self-confidence?
 Yes No

Do you feel that your hair loss adversely affects your self-esteem?
 Yes No

In which areas of your life do you feel your hair loss adversely impacts you?
 Home Life Work Life Social Life Dating Intimacy None

Are you ready to do something about your hair loss immediately?
 Yes No

Please offer us any additional information and/or comments regarding your hair loss

How did you hear about Abstrax Hair Designs?
---GoogleBingRadioTVWomen of Ocean CountyCelebrationsOther Local Circular