Questionnaire about Hair Loss

Online Email Consultation: In order for Dr. Li to have a clear picture of your situation, please fill out the short questionnaire below. If possible, attach photo(s) of the affected area at the bottom of this form. After you have submitted the form, you will receive a confirmation that your form was processed. The form will be sent directly to Dr. Li for her review. Please allow 1-2 business days for a response.**

Your name:
Patient Name (if different)
Your Email Address: (Required)
Verify Email Address: (Required)

Sex:
Age:
Race:

Weight:

Occupation:

Do you have family history of hair loss?

Does your scalp itch?

Do you have trouble sleeping?

Do you lose a lot of hairs in the shower?

Do you lose a lot of hairs when you comb your hair?

Do you have excessive hair loss on top of your head?

Do you have receding hair line?

How did you hear about us?


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

Please add any comments and questions you have below:

You may attach (optional) Pictures to help Dr. Li understand the situation:

Image1:

Image2:

Any personal information you submit to us is strictly confidential. Please take a look at our privacy policy to learn more.


**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.

Telephone: 1-888-880-1499
(within USA, CA) * 1-650-588-8335

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