Hair Loss Questionnaire Step 1 of 4 25% Date:* MM slash DD slash YYYY Personal InformationName:* First DOB:* MM slash DD slash YYYY Race:*Height*Weight*Hair Loss History and Hair Routine1. When did you last have a normal head of hair?*2. Was the onset of hair loss sudden or gradual?*3. Is your hair coming out “by the roots” or is it breaking off?*(Please shade in areas of the location of hair loss on the map to the right.)4. Is your hair thinning or is it shedding?*5. How often do you wash your hair?*6. What hair products do you use?*7. (i). Do you use hot rollers, ponytails, braids, twists, locks, extensions, or weaves?* Yes No (ii). How long do you leave hot rollers, ponytails, braids, twists, locks, extensions, or weaves installed for?(iii). How often do you do hot rollers, ponytails, braids, twists, locks, extensions, or weaves?8. Do you use hot combs, press and curl, curling irons or otherwise apply direct heat to your hair?* Yes No 9. (i). What type of hair chemicals do you use for your hair?*(ii) Is it a relaxer that contains lye?* Yes No (iii) Do you have a permanent wave?* Yes No (iv). Provide the name of the permanent wave or relaxer product(v). How long?(vi). How often do you straighten your hair?10. Does your scalp itch?* Little Moderate A lot Skin Disorders and Medical Supplements11. Do you get sores in your scalp?* Yes No 12. (i). Do you have seborrheic dermatitis?* Yes No (ii). Do you have Psoriasis?* Yes No 13. What medications are you allergic to?*14. (i). What medications do you take?*(ii) Do you use herbs or supplements?* Yes No (iii). Provide the herb or supplement names Hormones and Diet15 (i). If you are on birth control pills, which one?(ii) Have you recently started?* Yes No (iii) When did you start?(iv) Or have you stopped your birth control pills?* Yes No (v) When did you stop?16. (i) Are you on any other type of hormone treatment?* Yes No (ii) Which one?(iii) How long?(iv) Or have you stopped using hormone treatment?* Yes No (v) When did you stop?17. (i) If applicable, are your menstrual periods regular? Yes No (ii) Normal flow? Yes No 18. (i) Have you gone through menopause?* Yes No (ii) Age*19. (i) Are you on any type of weight loss diet?* Yes No (ii) Are you on a low protein diet?* Yes No (iii) Are you a vegetarian? if so what type? Family History and Medical History20. (i) Any hair loss in men in your family?* Yes No (ii) Baldness?* Yes No (iii) Any hair loss in women in your family?* Yes No (iv) How thin?(v) Any family history of thyroid disease, anemia, or lupus?21. What medical problems do you have?22. Do you have any of the following?*Select all options that apply to you.Severe headachesDouble visionExcess facial hairExcess body hairCystic AcneDischarge from breastDeepening of voiceEnlargement of clitorisPolycystic ovary diseaseNo23. Have you had in the last 3-12 months?*Select all the options that apply to you.High feverChildbirthSevere infectionFlare of chronic illnessMajor surgeryOver or under active thyroidLow protein dietLow iron in bloodSevere psychological stressStart or stop birth control pillsStart or stop hormone treatmentStart or stop beta blocker medicationNo24. Do you see a rash in your scalp or on your face? If yes, please describe.25. Treatments previously tried? (Rogaine, Vitamins, Shampoos, etc.)Email*
