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1 Hair Replacement Consultation Form: Have You Been Told You Suffer From: Yes No Alopecia Universalis? Alopecia Totalis? active Trichotillomania (hair pulling) Anxiety? Depression? Substance Abuse (treated/untreated) Nicotine Abuse (any form) Alopecia Totalis? active Trichotillomania (hair pulling) Current Prescription or Over-the-Counter Medications, Vitamins, Herbs, or Supplements: Do you take daily aspirin or other blood thinners like Coumadin, Plavix, etc.? Yes No Active and/or Inactive Medical Conditions: All Previous Surgical Procedures and Dates: How Long Have You Experienced Hair Thinning? Is Your Thinning Confined to the Top of the Head? (not sides or back)

2 Hair Texture: Fine Coarse Curly Straight Damaged Natural Hair Color?: Shampoo Type: Shampoo Frequency: What is your current hair loss concern? Starting to thin Advanced stage of thinning Overall thinning Receding hairline Bald spot forming in crown Little or no hair on top of the scalp Itching or flaking scalp Increased shedding Missing, damaged or sparse eyebrows Weak or sparse eyelashes Damaged or traumatized eyelashes Post-Plastic Surgery Hair Loss Visible Scar

3 Please check the box which most closely matches your hair loss pattern. Norwood 2 Norwood 2a Norwood 3 Norwood 3a Norwood 3 Vertex Norwood 4 Norwood 4a Norwood 5 Norwood 5a Norwood 6 Ludwig 1 Ludwig 2 Ludwig 3 Other (describe) What therapies have you tried? Propecia Rogaine (minoxidil) Saw palmetto/ other herbs, supplements Hair Transplantation Laser therapy Special shampoo Other Past Currently (Please specify):

4 If you camouflage your thinning/balding hair, which methods have you used? Past Currently Wig, toupee or weave Hair extensions Creative hairstyling (comb-over, perms) Powder or spray camouflage Age: Gender: Male Female What is your family's history of hair loss? Mother Father Maternal grandparents Paternal grandparents Brother/sister Don't know Your personal hair restoration objectives (check all that apply): Hairline restoration Increase in frontal density Crown coverage Stop hair loss / decrease shedding Touch-up, refinement or correction of previous procedure Scar Coverage Other (please explain):

5 Hair restoration solutions of interest: Surgical hair restoration (Follicular-unit micrografting, Linear harvest) Surgical hair restoration (Follicular-unit extraction: FUE/FOX) Medical therapy (Propecia, Minoxidil/Rogaine) Laser hair therapy (laser hood, laser comb) Nutritional supplementation Post-Plastic Surgery hair transplantation (describe below) Eyelash transplantation Eyebrow transplantation Beard/moustache transplantation Body-hair transplantation Scar coverage Other (please specify): Where are you in the hair restoration process? I've started researching my hair restoration options I'm interested in starting non-invasive treatment (Propecia, Minoxidil /Rogaine, Laser Therapy) I've had a hair transplant before I've had a consultation with another doctor I'm interested in scheduling a surgical procedure within the next ninety days I'm interested in scheduling a surgical procedure within the next year What is your current "Plan of Action?" (Check all that apply): I am interested in visiting the Madison, WI office for a procedure or other treatment. (Please indicate your time frame:) I would like to schedule an in-person consultation with Dr. Gencheff and Dr. Gerzenshtein in Madison, WI. I'm interested in completing a "Virtual Consultation" and having a preliminary evaluation using and photos. I will not be able to visit Dr. Gerzenshtein in Madison, WI USA for an evaluation, procedure or other treatment in the near future. Other (describe):

6 Interested in Eyelash Hair Replacement?: Please describe your current eyelashes: Why are you interested in the eyelash transplant procedure? Have your eyelashes been damaged or traumatized in any way? SAME 3 questions as above for eyebrows, sideburns How to contact you: (* Indicates required field) * First name: * Last name: * Best telephone number: * address: * Confirm address: Street Address: City: State/Province: Postal code: Please send me news and information Any additional comments or questions?

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