If you are going to be treated at our clinic please fill in this application form.
Primary consideration of your case is free.


The fields with asterisk (*) are obligatory

* Your First Name:
* Your Last Name:
Street Address / PO box: Street Address - pt II:
* City: State/Province: Zip/Post Code:
* Country:
* E-mail: * Confirm Email:
Daytime Phone: Evening Phone:
How did you Find us (if by the Internet please indicate search engine):
* Your Age:
* Gender:
Male:         Female:
The age when the first patch of hair loss occured:
The age when significant part of your scalp hair was affected:
* Total duration of the disease:
less than one year        less than 5 years        more than 5 years

I took the following medicines for Alopecia treatment according to doctor's prescription:

Prednizone or/and other steroid hormones as system (oral) treatment: Yes        No

If Yes, please write down the names:

Cytostatics: Yes        No

I was treated by:

Injections of corticosteroids directly onto and around the bald area(s) Yes        No
PUVA-therapy Yes        No
Have you got topical sensitizing therapy? Yes        No

If you do not know how to classify medicines and treatments just write them down:

I suntanned much with uncovered head for long periods of time: Yes        No
I wear a wig all the time: Yes        No
My finger and thumb nails have changed: Yes        No
My pubis and armpits are hairless: Yes        No
Question for Alopecia universalis sufferers only
Have your finger and thumb nails changed:
Yes        No

If yes, when in the course of the disease did your finger and thumb nails change (indicate details, if possible):

Have you ever noticed short hair (up to 6-8mm long) with thicker outer ends in the affected areas of the scalp (like the shape of exclamation mark)? Yes        No

If yes, in what period of the disorder:

The first bare patch appeared at the edge (hair line) of the scalp: Yes        No
The first bare patch appeared at the back of the head Yes        No

Please fill in any other questions, or comments:

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