Medical Questionnaire

IMPORTANT: For an adequate assessment your case, please send high resolution, detailed photos of your head/hair from all angles to consultations@brunoferreira.com. Please identify your email.

Identification
Name *
Name
Hair Loss
Please state if there is a background of hairless in your family, which family members and the degree of hair loss.
Hair Loss Progression *
Please check the treatments you are currently undergoing or medications you are taking. *
If "Other", state which.
Do you suffer from
If "Other skin conditions", state which.
If "Yes", where did you have it and who performed it?
Privacy Policy. *
We are committed to your privacy. Please take a moment to read our Privacy Policy.