Androgenetic Alopecia (Hair Loss) Pre-qualification Questionnaire

Thank you for your interest in this pre-qualification questionnaire. In order to determine if you pre-qualify for this research study, we will ask you a few questions about your Androgenetic Alopecia (AGA) commonly known as hair loss in men and women. You may stop answering at any time and do not need to answer any questions that make you feel uncomfortable. All information you provide will be kept confidential and stored in the secured study database. Your information will be kept in the secured database until the end of the study and then destroyed unless you elect to have us retain your information for potential future trials (see question 17 below).

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* 1. Are you 18-60 years of age?

Yes (please specify age)

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* 2. Please provide your contact information:

Name

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. For the phone number you provide above please specify:

Cell Phone

Home Phone

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* 4. Please confirm we can contact you by phone (text or call):

Yes

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* 5. What is your gender?

Male

Female

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* 6. Do you speak and read fluent English?

Yes

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* 7. Do you have access to internet connectivity?

Yes

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* 8. Have you been diagnosed with Androgenetic Alopecia (typical hair loss) by a physician?

Yes (please specify year)

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* 9. Have you undergone a hair transplantation procedure?

Yes

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* 10. Males: Which set of photos best describes your hair loss pattern?

Not applicable because I am a female or none of the photo(s) above represent my hair loss.

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* 11. Females: Which set of photos best describes your hair loss pattern?

Not applicable because I am a male or none of the photo(s) above represent my hair loss.

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* 12. To pre-qualify, you must submit non-identifying photo(s) of your balding scalp. Are you willing to upload and submit photo(s)? See question #13 for an example of the photo(s).

*Please note, the photo(s) will be stored in a secured study database and reviewed by study staff.

Yes

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* 13. Photos to be uploaded should resemble the following examples:

Male Sample Photo 1:

Male Sample Photo 2:

Female Sample Photo 1:

Female Sample Photo 2:

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* 14. Please upload and attach one photo of the top of your scalp displaying your hair loss as shown in the samples above.

Reminder: No full face photo(s).

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 15. Please upload and attach one photo of the back of your scalp displaying your hair loss as shown in the samples above.

Reminder: No full face photo(s).

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 16. How did you hear about this study?

Craigslist Ad

Facebook Ad

Google Ad

Other (please specify)

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* 17. May we retain your information so we may contact you about potential future studies?

Yes

Thank you for your answers! If you pre-qualify, a team member will contact you soon.

Androgenetic Alopecia (Hair Loss) Pre-qualification Questionnaire

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* 1. Are you 18-60 years of age?

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* 2. Please provide your contact information:

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* 3. For the phone number you provide above please specify:

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* 4. Please confirm we can contact you by phone (text or call):

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* 5. What is your gender?

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* 6. Do you speak and read fluent English?

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* 7. Do you have access to internet connectivity?

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* 8. Have you been diagnosed with Androgenetic Alopecia (typical hair loss) by a physician?

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* 9. Have you undergone a hair transplantation procedure?

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* 10. Males: Which set of photos best describes your hair loss pattern?

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* 11. Females: Which set of photos best describes your hair loss pattern?

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* 12. To pre-qualify, you must submit non-identifying photo(s) of your balding scalp. Are you willing to upload and submit photo(s)? See question #13 for an example of the photo(s). *Please note, the photo(s) will be stored in a secured study database and reviewed by study staff.

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* 13. Photos to be uploaded should resemble the following examples:

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* 14. Please upload and attach one photo of the top of your scalp displaying your hair loss as shown in the samples above.

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* 15. Please upload and attach one photo of the back of your scalp displaying your hair loss as shown in the samples above.

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* 16. How did you hear about this study?

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* 17. May we retain your information so we may contact you about potential future studies?

* 12. To pre-qualify, you must submit non-identifying photo(s) of your balding scalp. Are you willing to upload and submit photo(s)? See question #13 for an example of the photo(s).

*Please note, the photo(s) will be stored in a secured study database and reviewed by study staff.