Hair Regrowth Medical Questionnaire
This medical questionnaire is designed to ensure that you are suitable for the hair regrow treatment.
Date of Birth* (dd/mm/yyyy):
Please describe your hair loss history
Any previous hair loss treatment?
Have you been diagnosed or suffer from:
Iron Deficiency *
Thyroid Disease *
Other Hormonal Issues *
Hypertension (high blood pressure)*
Chronic Illness *
Blood Pressure & Date taken
List all current medications / daily does / frequency (including over the counter medications, vitamins and minerals)
Please list any allergies you have
Send in two photos of your hair (front and top of head) via email to
with these photos attached.
I confirm there is no other information that I am aware of that would influence the medical treatment / advice to be provided.