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  1. First Name(*)
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  10. Age
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  11. Gender(*)
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  12. Type of Hair and Ethnicity(*)
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  13. Which treatments are you interested in? Choose all that apply. (Use CTRL-click to select multiple)(*)
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  14. What best describes your hair loss condition?(*)
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  15. How long have you been experiencing hair loss?(*)
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  16. Is your scalp visible in the area where you have lost your hair?(*)
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  17. Do you suffer from any of the following conditions? Choose all that apply. (Use CTRL-click to select multiple)(*)
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  18. Have you attempted to do anything about your hair loss situation? Choose all that apply. (Use CTL - click to select multiple)
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  19. Have you consulted a doctor or other professional about your hair loss?
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  20. How often do you think about your hair loss situation?
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  21. Do you feel that your hair loss prohibits you from being "who you really are"?
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  22. Do you feel that your hair loss adversely effects your self-confidence?
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  23. In which areas of your life do you feel your hair loss adversely impacts you? Choose all that apply. (Use CTRL-click to select multiple)
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  24. How do you feel we can best serve you?
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  25. Are you ready to do something about your hair loss immediately?
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  26. Please offer us any additional information and/or comments regarding your hair loss(*)
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  27. How did you become aware of HRC?
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  28. If you chose "Other", please specify:
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  29. Are you Human?
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