FEMALE HAIR LOSS STUDY — Pre-Screening

Full Name

Email Address

Phone Number

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1980)

City and State

Do you consent to be contacted for future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Are you female?

Yes No

What is your age?

Must be between 18 and 65 years.

Have you been clinically diagnosed with mild to moderate androgenetic alopecia (AGA) or female pattern hair loss?

Yes No

Female hair-loss pattern reference chart

Click image to open enlarged version

Which image best represents your current hair loss pattern?

I-1 I-2 I-3 I-4 II-1 II-2 III Advanced Frontal

Select the single pattern that most closely matches your hair loss.

Are you currently in generally good health?

Yes No

Have you been told you have kidney or liver problems?

Yes No

Are you willing to maintain at least 1/4 inch hair length and keep the same hairstyle, hair length, and hair color throughout the study?

Yes No

Are you willing to keep your regular hair care products and hair care routine consistent during the study?

Yes No

Are you able to read, understand, and complete questionnaires in English?

Yes No

Are you able and willing to swallow oral tablets whole?

Yes No

Are you willing to have a small micro-dot tattoo placed on your scalp for study measurements?

Yes No

Are you willing to have photographs taken of your scalp during study visits?

Yes No

Do you currently have uncontrolled high blood pressure or experience dizziness when standing due to low blood pressure (orthostatic hypotension)?

Yes No

Have you ever been diagnosed with significant heart conditions?

Yes No

Have you ever been diagnosed with thyroid disease or thyroid-related conditions?

Yes No

Do you have hair loss caused by any condition other than androgenetic alopecia (AGA)?

Yes No

Have you recently experienced major dietary changes or significant weight changes?

Yes No

Have you used GLP-1 medications for weight loss or diabetes recently (examples include Ozempic, Wegovy, Mounjaro, Zepbound)?

Yes No

Have you been diagnosed with COVID-19 within the last 16 weeks?

Yes No

Have you ever received radiation treatment to your scalp?

Yes No

Have you used hormone replacement therapy or hormonal modulators within the past 6 months?

Yes No

Have you used oral medications for hair growth or medications that may affect hair growth (including systemic retinoids) within the past 6 months?

Yes No

Have you used systemic calcium channel blockers or beta blockers within the past 12 weeks?

Yes No

Have you used cimetidine, ketoconazole, diazoxide, or systemic corticosteroids (including injections) within the past 12 weeks?

Yes No

Have you had scalp procedures within the past 6 months, including surgery, laser/light treatments, microneedling, injections, or platelet-rich plasma (PRP)?

Yes No

Have you used topical scalp treatments for hair growth within the past 12 weeks?

Yes No

Are you currently using any other medication or therapy that may affect hair growth?

Yes No

Do you have any other medical condition that may interfere with participation in this study?

Yes No