Questionnaire about Hair Loss

Please answer a few questions so that we can better understand your situation.**

If you like to send us your picture, please send it with your name to doc@merryclinic.com

Your name:

Patient Name (if different)

Your Email Address:

      

Verify Email Address:

  

Age:          

Sex: Male   Female

Race:

Weight:    (pounds)
Does your scalp itch? Yes  No

Do you have family history of hair loss?

 Yes   No
Do you have trouble sleeping? Yes   No
Do you lose a lot of hairs in the shower? Yes No
Do you lose a lot of hairs when you comb your hair? Yes No
Do you have excessive hair loss on top of your head? Yes No
Do you have receding hair line? Yes No
 How did you hear about us?


Please Specify: (such as Google, WebMD, etc..)

   

Please add any comments and questions you have below:

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**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.