Let us help you with your hairline

Is hair loss causing you anxiety and stress?

Did you know that there are many medical based hair loss solutions available (SUITABLE FOR  BOTH MALES AND FEMALES) that can restore your hair – no matter how bad you think it is.

Simply complete the below evaluation form and we will be in touch at a suitable time to organise your consultation and then organise any prescribed products to be delivered directly to you.

MedHead Hair Loss Evaluation form (Males)

Full Name *

Email Address *

Phone *

Age *

How did you hear about us?

HAIR LOSS HISTORY

Which best describes your hair loss *

On the vertex (top of head/crown)

Mainly around the front hairline

Vertex (top of head/crown) & front hair line

All over thinning

Noticeably balding - very little hair all over scalp

Patchy (hair loss in random places)

Patchy (have been diagnosed with Alapecia Areata

Totally Bald

Totally Bald (have been diagnosed with Alapecia Totalis)

Other - please provide details:Other - please provide details:

How long have you experienced noticeable hair loss? *

1-2 months

Up to 6 months

Up to 1 year

More than 1 year

Since that time have you noticed any changes? *

About the same

Better

Worse - please provide details:Worse - please provide details:

How rapid was your hair loss? *

Sudden

Gradual

Sporadic (no set pattern)

Other - please provide details:Other - please provide details:

Do you colour your hair or have it chemically straightened, etc? *

Yes, frequently

Yes, sometimes

Yes, but rarely

No

Other - please provide details:Other - please provide details:

Do you feel your hair is thinning without actually seeing excessing falling hair? *

Yes

No

Other - please provide details:Other - please provide details:

Are you currently undertaking any treatment for your hair loss - either prescription or non-prescription? *

No

Yes - please provide details:Yes - please provide details:

Within 6 months prior to the onset of hair loss, had you started taking any new medications? *

No

Yes - please provide details:Yes - please provide details:

MEDICAL HISTORY

Do you suffer from any of the following:

Low Hormone levels

Low Testosterone

High Testosterone

Low Libido

Thyroid disorder

Auto-immune condition

IBS/Bowel disease

Coeliac disease/Gluten intolerance

Low Iron

Low B12

Food Allergies

Scalp infection

Dandruff/Scalp dryness/Flaking

Kidney Stones

Kidney disease

Other -please provide details:Other -please provide details:

Please check all that apply to you

SURGERIES

Please provide Surgery Name & Date

ALLERGIES

Any Known Allergies?

No

Yes

If Yes, List and describe reaction

Do you feel like you are under stress? *

No

Yes - please provide details:Yes - please provide details:

Are you actively dieting? *

No

Yes - please provide a brief summary:Yes - please provide a brief summary:

CURRENT MEDICATIONS

Please provide details of any prescription medications and dosage (in none, please state N/A) *

Please provide details of any supplements (in none, please state N/A) *

Please include any other information not listed, but you feel may be relevant:

If you have had blood tests taken in the last 6 months or any other information, or photos you would like to supply, please upload a copy here:

Drop a file here or click to upload Choose File

Maximum file size: 10MB

Please advise suitable time for our consultant to call you: *

Morning

Afternoon

Evening

OtherOther

DELIVERY ADDRESS

Address *

Suburb *

State *

Postcode *

I confirm that the information I have provided on this form will be used to determine the best hair loss treatment options for me and is true and correct to the best of my knowledge *

Yes

PRINT FORM As some browsers have an issue with this form, please print a copy of your completed form (or save as PDF) before you hit the SEND button below. Your completed form can then be emailed to us at info@hcgprotocol.com.au. If you still have issues with this form, please contact us at info@hcgprotocol.com.au and we will send you a form to complete manually.

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