Form - Minoxidil – DIMA Health Technology Inc.

You're just a few questions away from regrowing your hair!

Please fill this questionnaire to complete your order.

Please enter your first name:

Please enter your last name:

Please enter your email:

What was your sex assigned at birth?

Male

Female

How old are you?

What type of hair loss are you experiencing?

Female pattern hair loss (thinning on top)

Patchy hair loss (alopecia areata)

Hair loss due to tight hairstyles (traction alopecia)

Hair shedding after stress or pregnancy (telogen effluvium)

Not sure

How long have you been noticing hair loss?

Less than 3 months

3-6 months

6-12 months

Over 1 year

Not sure

How would you describe your hair loss?

Mild (slight thinning)

Moderate (noticeable thinning)

Severe (significant hair loss)

Not sure

Have you tried any hair loss treatments before?

Minoxidil (topical or oral)

Biotin or other supplements

Shampoos or serums

None

Do you have any of the following health conditions? (Select all that apply)

Are you currently pregnant or breastfeeding?

Pregnant

Breastfeeding

Neither

How frequently do you feel stressed in your daily life?

Never

Rarely

Sometimes

Always

Do you have a family history of thinning hair?

Yes

No

Not sure

Are you currently taking any medications?

Do you have any known allergies to medications?

What are your hair regrowth goals?

Stop hair loss

Regrow hair

Improve hair thickness

Prevent future hair loss

Not sure

Thank you for filling the form!

You can now select products you want to add to your cart: