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* Name:
Spouse:
* Address:
* City:
* State:
* Zip:
* Email:
* Date of Birth:
select
* Home Phone:
Cell Phone:
Business phone:
* Occupation:
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The following information will help your Cirrus consultant answer every concern you may have about your hair loss.
Each answer is important, as it helps determine which of the many Cirrus options you will gave to choose from, and will help define the exact costs for that answer,
as well as the results you may expect.
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1.
This is the first contact you've made with a hair restoration specialist?
2.
Have you puchased any type of hair system in the past?
What type
3.
Do you know any Cirrus Hair Center client?
Name
4.
Have you used any over-the-counter or prescription solutions to hair loss?
What product
5.
If you have tried Rogaine, were you pleased?
what were the results?
Excellent
Good
Mixed
Poor
6. How long did you use Rogaine or other products?
0 - 4 Months
4 - 12 Months
12 Months +
7. How active are you?
Somewhat active
Moderately active
Very Active
8. Please check any sports activities you participate in.
9. How old were you when you first noticed significant hair loss?
15-20
21-25
26-30
Over 30
10.
Your hair is beginning to turn gray?
11.
You color your hair?
12. Please indicate areas in which your hair loss concerns you.
When meeting new people
Hearing comments about the loss
Windy days
When swimming
Seeing old friends again
13. I think hair loss affects.
My self esteem
My overall appearance
How I look when dressed up
How often I wear a cap or hat
My playing sports
14. Did any of the following have moderate to severe hair loss on your father's side of the family?
Your father
His father
Any Uncles
Any Aunts
15. Did any of the following have moderate to severe hair loss on your
mother's side of the family?
Your mother
Her father
Any Uncles
Any Aunts
16.
Your brothers or sisters have moderate to severe hair loss?
17. Is there any one factor, more than others, that concerns you most about your hair loss?
18. How did you hear about Cirrus?
Referral
TV - ch
Newspaper
Radio station
Yellow Pages
Other
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