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    Title *
    Hair type *AfricanAsianEuropean
    Hair structure *CurlyFineFrizzyMediumStraightThick
    Hair color *BlackBlondBrownWhite
    Is there a family history of hair loss *YesNo
    Type of hair loss *Alopecia androgeneticaAlopecia cicatricalisDiffuse hair lossOther
    Duration of your hair loss *MonthsWeeksYears
    Which area(s) are affected by hair loss *DiffuseOn topComplete hair lineIndentationsBack of the scalp
    technique *BothFollicular Unit Extraction (i.e. extraction of the units one per one)Follicular Unit Strip Transplantation
    Are you presently treating your hair loss or did you already treat your hair loss in the past with one of the medications underneathfinasteridedutasterideRogaineMinoxidilNoneOther