Hair Growth Supplement Daily Use Intake Form
Please complete this form each day to help us monitor your supplement usage and overall experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Intake
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which hair growth supplement are you using today?
*
Please Select
Biotin Supplement
Collagen Supplement
Saw Palmetto Supplement
Multivitamin for Hair
Other
What dosage did you take today? (e.g., number of pills, mg, etc.)
*
Did you take your supplement as scheduled today?
*
Yes
No
If you missed your supplement today, please select the reason(s):
Forgot
Ran out of supplement
Experienced side effects
Not feeling well
Other
Did you experience any side effects today?
*
No side effects
Mild (e.g., stomach discomfort)
Moderate (e.g., headache, nausea)
Severe (e.g., allergic reaction)
Please describe any side effects or symptoms you experienced today (if any).
How would you rate your overall experience with the supplement today?
1
2
3
4
5
Additional comments or feedback about your experience today
Submit Daily Intake
Should be Empty: