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Confidential Questionnaire:
Age: Gender :
Family history of thinning/baldness:
Marital Status:
Male Pattern of hair loss - Check the stage that most closely resembles your hair loss








Female Pattern of hair loss - Check the stage that most closely resembles your hair loss



 
Please Indicate:
Tried
Might Try
Won't Try
Don't Know
 
Over-the-counter treatment (Shampoos,
Herbs, Sprays, Rogaine®)
 
Prescription Medication(Propecia®)
 
Toupees, Wigs, Weaves
 
Surgical Treatment
 
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Bauman Medical Group helps patients worldwide in restoring their own living and growing hair.

Bauman Medical Group, P. A. - 6861 SW 18th Street • Suite 102
Boca Raton, FL - 561.394.0024 - Fax: 561.394.4522
doctorb@baumanmedical.com
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