2. Choose the color below that most closely describes your natural hair color?

Black

Red

Brown

Red-Brown

Blonde

Gray

Salt and Pepper

Other: (Please Specify)

4. Please mark how often you groom your hair in each of the following styles.

Natural
Braids
Pony Tail
Weave
Corn Rows
Straight
Waves
Sister Locks
Twists
Wig

(1 = Never, 2 = Seldom, 3 = Occasional, 4 = Often, 5 = Most of the time, 6 = Always)

5. Regarding Straightening, how often have you done the following?

Chemical
Flat Iron
Keratin and Blow-Dryer

(1 = Never, 2 = Occasionally, 3 = Off and on over the years, 4 = Moderate Use; stopped more than 3 months ago, 5 = Heavy use; stopped more than 3 months ago, 6 = Currently using)

6. Please state how often you wash your hair.

Water
Soap
Shampoo

(1 = 7 times a week, 2 = 3-4 times a week, 3 = 1-2 times a week, 4 = Every 2 weeks, 5 = Every 3 weeks, 6 = Every 4 or more weeks)

7. Please state how often you Condition your hair.

Using Conditioner
Using Oils
Defrizzer/Detangler
Pomade

(1 = 7 times a week, 2 = 3-4 times a week, 3 = 1-2 times a week, 4 = Every 2 weeks, 5 = Every 3 weeks, 6 = Every 4 or more weeks)

8. Please indicate your use of the following nonprescription hair treatments.

Minoxidil
Laser caps or laser combs

(1 = Never used, 2 = Used more than a year ago, 3 = Used 6 months ago, 4 = Used 3 months ago, 5 = Currently using)

9. If you have tried other hair treatments what has been your experience? (Specify Product Name)

Didn't work at all
Worked somewhat
Worked very well
Might have worked if I continued to use it
Had a reaction to the product
Liked it but dried out my scalp too bad
Made my scalp itch
Couldn't stand the smell
Product did not penetrate my hair
Worked in some areas but not others
Made the problem worse

10. Referring to the pictures on the hair loss chart provided at the end of this questionnaire, please indicate the extent of hair loss. (Female)

1-2

11-2

111

Advanced

Frontal

Traction Alopecia

11. If you have ever been treated by a doctor for hair loss what was the diagnosis?

Never treated by a doctor for hair loss

Androgenic Alopecia (genetics)

Traction Alopecia (from pony tails, tight braids, etc)

Central Centrifugal Cicatricial Alopecia (CCCA) (Chemical or hot comb induced)

Lichen Plano Pilaris (LPP)

Frotal Fibrosing Alopecia (FFA)

Alopecia areata

Lupus

Dandruff/severe scalp dryness and flaking

12. Mark any of the following tests you've had for hair loss. Mark all that apply.

Hair pull test

Blood work

Scalp Biopsy

Other: (Please Specify)

13. If you've ever been treated by a doctor for hair loss, please provide the doctor's name and contact information below.

14. If you've ever been treated by a doctor for hair loss, please provide the type of treatment, duration of treatment.

Minoxidil

Finasteride

Hydroxychloroquiine/Plaquanil

Doxycycline/Minocycline

Platelet Rich Plasma

Microneedling

Mesotheraphy

Scalp Steriod Injections

Other: (Please Specify)

15. Mark any of the following conditions that you have. Choose all that apply.

High blood pressure

Low blood pressure

Dizziness

Fainting spells

Other: (Please Specify)

16. Please list any prescription medications you are currently taking or have taken in the past.

17. Please list any over-the-counter medications you are currently taking or used in the past.

18. Please list any herb, vitamins, or natural supplements you are taking or used in the past.

19. Please indicate if you are allergic to any of the following. Check all that apply.

Any plant or plant extract

Any flower or flower extract

Any oils

Other: (Please Specify)

20. Please use the space below to explain anything else you think would be helpful for us to know about your hair condition hair grooming habits or medical condition that we did not thing to ask.

Send head shots that show the balding areas. Please pull back any hair that obscures the true state of your hair line. If possible also send some photos with the entire top of the head wetted.

Include the photos of the side and back of your head. If you are having body hair transplanted, please include photos of the hair bearing areas of your body from which you want the hair taken.

If you are unsure, send photos of all hair bearing areas. Include photos of special recipient areas such as scars, eyebrows, eyelashes, mustaches, etc.

5MB Max file size limit, PHOTOGRAPHS UPLOAD: