Virtual Consultation for Men

Welcome to Ultra Hairs Virtual Consultation for Men.

The condition of your hair is a concern? We understand. And this virtual consultation will bring you one step closer to finding the hair solution that will work best for you.

By filling out this questionnaire, you will help us learn a little more about your particular hairloss situation. We will then be able to establish a preliminary diagnosis, and suggest appropriate hair alternatives.

Rest assured that this virtual consultation is a matter we treat with the utmost privacy and we will never disclose your information to any third parties. Also keep in mind that this form and any reply to it cannot take the place of an actual in-person consultation.

STEP 1: IDENTIFICATION	* (denotes required information)
First Name *
Last Name *
Date of birth	(yyyy-mm-dd)
Address
City *
Province *	Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories
Postal Code
Occupation
Home phone
Cell phone
Best time to be reached	Monday Tuesday Wednesday Thursday Friday Saturday Sunday Day Night
E-mail *

 

STEP 2: QUESTIONNAIRE
Do you have an active lifestyle?	Yes No
If yes, what type of sports do you practice?
What are your expectations from Ultra Hair?	Stop your hair loss Have more hair Treat a specific problem Other
When did your hair start thinning?
How would you describe your current hair loss	10-20 hairs a day 21-40 hairs a day 41-99 hairs a day More than 100 hairs a day
Does baldness/thinning hair run in your family?	Yes No
Have you seen a physician regarding your hair loss?	Yes No
If yes, what was his recommendation?
What product(s) do you use on your hair?	Shampoo   times/week Which one?  Coloration   times/month Other product(s)
Are you on a hair treatment program?	Yes No
If yes, which one and what are the results?
Do you suffer from:	Dandruff Itchy scalp Dry scalp Oily scalp Other
If other, please specify:
Would you characterize your existing hair as:	Dry Oily Normal
The hair you are loosing is:	Coming out with the root It is breaking
Does your scalp excrete excessive sebum (oil)?	Yes No
Are you presently experiencing: (hold "ctrl" to select more than one)	- please select - Professional Stress Medical Treatment Personal Stress Sickness Severe Diet Menopause Medication Pregnancy
If yes, please describe:
On a scale from 1 to 10, how would you rate the emergency to treat you hair loss?
Less Urgent – 1 2 3 4 5 6 7 8 9 10 – More Urgent
Who supports your decision to treat your hair loss?
How would you like your new "look" to be?
Do you presently have or have you ever had any type of surgical or non-surgical hair replacement? Yes No
On the chart below, what image best represents the current status of your hair loss?

 

I understand that the information I provide will be kept in complete confidentiality and will not be distributed, sold or used for any other purposes than for us to communicate with you.