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You're just a few questions away from regrowing your hair!
Please fill this questionnaire to complete your order.
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Please enter your first name:
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Please enter your last name:
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Please enter your email:
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What was your sex assigned at birth?
Male
Female
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How old are you?
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Where are you noticing hair loss or thinning?
Receding hairline (along my forehead or temples)
Thinning crown (top of my head)
Both hairline and crown
Random, patchy hair loss scattered all over my scalp
Nowhere yet, but I'd like to prevent future hair loss
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How would you rate your hair loss?
Mild
Moderate
Severe
Extremely Severe
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What was your latest blood pressure reading in the last 6 months?
If you have 'Very High' or 'Low' blood pressure, it might not be safe to take Sildenafil.
Low
Normal
High
Very High
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Have you taken any hairloss medications before?
Yes, Finasteride or Propecia
Yes, Minoxidil
Not Yet
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Please select any that apply to you:
Heart issues
Pericarditis
Arrythmia
Repeated chest pain or tightness, also called angina
Coronary artery disease, or narrowing of the heart vessels
Pheochromacytoma (adrenal gland tumor)
Pulmonary hypertension
Prostate cancer
Kidney issues
Liver issues
Erectile dysfunction
Low blood pressure
Anxiety or depression
You are using any medicine containing nitrates, nitroglycerin, iso-sorbide, or any other forms of nitrates
None of the above
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If you have any medical condition not listed previously, please list them below.
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If you have had any surgeries or hospitalizations please list them below.
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If you are taking any medications please add them below.
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If you have any allergies to medications, please list them below.
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