Patient Questionnaire

To begin consultation on your hair loss treatment, please complete the questionnaire below. The information will be reviewed by our staff in order to offer you the most suitable options for the treatment.

Contact details

Please specify your E-mail or phone number to enable us to contact you.

Additional information
Level of hair loss (Norwood scale)

Mark the drawing that corresponds most closely to your hair (when wet).


I level of hair loss
II level of hair loss

III level of hair loss
III vertex level of hair loss

IV level of hair loss
V level of hair loss

VI level of hair loss
VII level of hair loss
Level of hair loss (Ludwig scale)

Mark the drawing that corresponds most closely to your hair (when wet).


I level of hair loss
II level of hair loss
III level of hair loss
Some more important questions
Has the intensity of hair loss increased within the last 5 years?
Yes No
Have you consulted with a hair loss specialist before?
Yes No
Have you ever received surgery for hair restoration?
Yes No
Do you expect that surgical hair restoration will solve your hair loss problems?
Yes No
Please attach photos of the balding areas and of the back of your head.
Important: If the photos are large, you may have to wait for a while for the photos to be uploaded after pressing the “Submit” button.

If you have any comments or information that will help us to understand your problem better, please supply it below: