Question 3

As of today, have you received the prescription bottle from the Study Sponsor? *

Yes

No

Since the start of the study I feel I am losing more hair than before the study. *

Agree

Strongly Agree

Disagree

Strongly Disagree

For about how long have you been in this study?

Approximately 30 days

Approximately 60 days

Approximately 90 days

Approximately 120 days

Approximately 150 or more days

Since the start of the study I feel I have more hair due to my use of the Study products. *

Yes

No

If you have received and begun to use the Precription element - please let us know when you began. Please note exact date.

Because of the Study products I have used since the start of the study, my hair seems to be growing *

Agree

Strongly Agree

Disagree

Strongly Disagree

How effective do you think the treatment has been so far in slowing down your hair loss? *

Effective

Not Effective

Mildly Effective

Highly Effective

Since the start of the study I feel I see less of my scalp? *

Agree

Strongly Agree

Disagree

Strongly Disagree

Since the start of the study How often have you used the Conditioner?

Everyday

Every other day

1 to 2 times per week

1 to 2 times per month

Haven’t used it yet

Since the start of the study how often have you used the Foam?

Everyday

Every other day

1 to 2 times per week

1 to 2 times per month

Haven’t used it yet

For the Term you have been in the study you have used....the (please check all that apply)

Shampoo

Foam

Conditioner

Prescription Hair Growth Gel

Age: *

Name: *

Since the start of the study how often have you used the Shampoo?

Everyday

Every other day

1 to 2 times per week

1 to 2 times per month

Haven’t used it yet

IF YOU have received the Prescription Bottle - have you begun to use?

I have not received

Yes

No

No I am waiting for Ed to OK