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Hair Growth Online Test

This is a validated questionnaire to help identify and help men who have a problem with Hair Loss.
Treatments are available to help you manage this condition.

These Online Tests are simple questionnaires that are submitted to our Doctors to see if Essential Men's Clinic has a solution that is right for you. They are obligation free and absolutely confidential.

* Indicates required field

How did you hear about this site? *

Internet Search Google Adwords Facebook Instagram Friend Other

If Other please specify *

Which Essential Mens Clinic? *

Auckland Remuera

Name *

First

Last

Date of Birth *

Age *

Email *

Phone Number *

Region You Reside *

HAS YOUR HAIR LOSS WORSENED RECENTLY? YES OR NO. *

WHEN DID YOU FIRST START LOSING YOUR HAIR? *

IS YOUR HAIR LOSS *

Diffuse Patchy Other

Please Explain *

FAMILY HISTORY HAIR LOSS? *

Yes No

If So Who? *

WHICH HAIRLOSS TYPE DO YOU HAVE? *

DESCRIBE YOUR GENERAL HEALTH *

Good Average Poor

Please Explain Why *

ANY SERIOUS ILLNESS PAST FEW YEARS, DESCRIBE. WRITE NIL IF NONE. *

PAST MEDICAL HISTORY. HAVE YOU HAD ANY OF THE FOLLOWING? *

Anaemia/Iron Deficiency Autoimmune Disorder Arthritis Inflammatory Bowel Disease Diabetes Thyroid Disease Over &/Or Underactive Kidney Disease Liver Disease Cancer Radiation or Chemotherapy Mental Illness Depression Emotional Stress Or Anxiety Previous Hair Transplant or Scalp Surgery Previous Treatment for Hair Loss Skin Infections Fungal Bacterial Viral Chronic HSV Significant Illness Or Disease Significant Trauma Significant Surgery Significant Weight Loss Other NONE OF THESE

Please explain or expand on all of those you have clicked on for above *

LIST ALL CURRENT MEDICATIONS. WRITE NIL IF NONE *

List Medicines when hair started falling out. for example Antihistamines, Cholesterol Meds. Write Nil if None *

ALLERGIES TO MEDICINES OR OTHER. WRITE NIL IF NONE *

DIETARY CONSIDERATIONS. TICK ANY OF THE FOLLOWING THAT APPLY? *

Are You A Vegetarian Have High Processed Carbohydrate Intake Have High GI Food Intake Dieting Recently Iron Deficiency Nutritional Deficiency Zinc Deficiency High Vitamin A Intake High Whey Protein Intake Testosterone Boosters Or Analogues NONE OF THESE

Please explain or expand on all of those you have clicked on for above *

PERSONAL SOCIAL. DO YOU SMOKE? *

Yes No

ANY OTHER COMMENTS THAT MAY HELP US. *

Submit

Please note that by submitting this form you will be signed up to the Essential Mens Clinic Newsletter. We respect your privacy and you can unsubscribe at anytime.

Our Doctors will respond to your submission from your given email address.
Your personal details will remain confidential and not disclosed to any third parties.
You have the right to view, change or delete this information on request.
This questionnaire is not comprehensive, and does not replace a full history and physical examination and further information may be necessary on follow-up.
Due diligence will be exercised for making a thorough assessment.

Want to know more about PRP Hair Growth? Watch this video:

Book Your Consultation

Reception 09 523 5999

Men's Corner
P Shot® or Priapus Shot®
P-Long® Protocol
Extracorporeal Shock Wave Therapy
Bocox®
Peyronie's Disease
Erectile Dysfunction
Premature Ejaculation

Hair Growth
Pharmaceutical
PRP Hair Growth

Face Aesthetics
Wrinkle
Dermal Filler
Cosmetic Aesthetics
IPL-Intense Pulse Light
Mole Removal

Body Aesthetics
Excessive Sweating
IPL-Intense Pulse Light
Mole Removal

Opening Hours Remuera

Monday 10-6pm
Tuesday 10-6pm
Wednesday 10-6pm
Thursday 10-6pm
Friday 10-6pm

Not open weekends or public holidays.
Howick hours please contact reception
09 523 5999

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'Confidentiality assured' Dr Mark Morunga

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