Please tell me more about your hair loss condition by answering the following questions. For some questions you will need to mark the YES or NO box at the right. For other questions, simply write your answers in the spaces provided.

1. When did you FIRST notice that you were losing your hair? *

What did you notice at that time? *

Hair “coming out” or Shedding

Hair looked thinner on scalp

Other

If other, please specify

2. Have you recently noticed that your hair loss was worsening? *

YES

If yes, when did you begin to notice it was worsening?

3. Please mark the box that best describes your family members’ scalp hair (If you have more than one brother or sister, mark the box that describes the brother or sister who has the least amount of hair):

Father *

Mother *

Brother *

Sister *

4. Have you been pregnant at any time before or during the hair loss? *

YES

If yes, when did the pregnancy end?

5. Have you had a serious illness at any time before or during the hair loss? *

YES

If yes, please describe the illness and state when it occurred

6. Have you been hospitalized at any time before or during the hair loss? *

YES

If yes, why were you hospitalized and when did you leave the hospital?

7. Have you been under a severe amount of stress at any time before or during the hair loss? *

YES

If yes, when did it start and end?

8. Have you started any special diets at any time before or during the hair loss? *

YES

9. Are you a vegetarian? *

YES

10. Please list the names of all the medications you are currently taking in the space below. Check the ones that you were taking when your hair began to fall out. *

1
2
3
4
5

11. Please list any additional medications that you were taking when your hair began to fall out that you are no longer taking: *

1
2
3
4
5

12.Please list any vitamins or natural products that you are taking:

1
2
3
4
5

13. Are you menopausal?

YES

If you are menopausal, when did menopause occur?

If you are menopausal, were your periods (menses) regular prior to menopause? *

YES

14. If you are not menopausal, do you get your menstrual period every month? *

YES

If yes how often does your period come?

15. Have you ever needed to take birth control pills to make your periods regular? *

YES

16. Do you have unwanted or excessive hair growth on your body? *

YES

Where is the unwanted/excessive hair growth located?

17. Do you have hair loss anywhere else on your body? *

YES

Where (other than the scalp) is the hair loss located?

18. Do you have any abnormal fingernails or toenails? *

YES

If yes, please describe the problem

19. How often do you wash/shampoo your hair?

20. How often is your hair chemically processed or straightened (relaxers, Japanese straightening, other)? *

21. How often is your hair heat processed or straightened (e.g. blow drying/ flat ironing, curling iron)? *

22. How often is your hair dyed, highlighted or otherwise color treated? *

23. Please check all hair styling practices that you have done in the past *

Braiding

Weaves

Tight hairstyles (e.g. ponytails)

(Other)

If other, please specify

24.Have you had a biopsy of your scalp to evaluate your hair loss problem? *

YES

25. Have you had blood tests done to evaluate your hair loss problem? *

YES

What tests were done?

26. Have your hormones ever been checked to evaluate your hair loss problem? *

YES

What was the result?

27.Have you ever been told by a doctor that you have a thyroid condition? *

YES

28. Have you ever been treated with thyroid hormone? *

YES

29.Have you ever been told by a doctor that you have a low iron level? *

YES

30. Do you (or a family member) have any autoimmune diseases? *

YES

Check all that apply:

Lupus

Self

Family member

If any from family member

Rheumatoid Arthritis

self

family member

If any from family member

Celiac disease

self

family member

If any from family member

Type 1 diabetes

self

family member

If any from family member

Sjogren’s disease

self

family member

If any from family member

Vitiligo

self

family member

If any from family member

31.Do you have symptoms on the scalp (e.g. itching, pain, burning)? *

YES

If yes, indicate which symptom(s) has occurred (please check all that apply):

itching

tenderness

pain

burning

Where on the scalp do the symptoms occur?

Please list all the prescription and non-prescription treatments that you have tried for your hair loss condition:

Treatment 1

Treatment
When was it tried?
For how long?
Did it help?

Treatment 2

Treatment
When was it tried?
For how long?
Did it help?

Treatment 3

Treatment
When was it tried?
For how long?
Did it help?

Treatment 4

Treatment
When was it tried?
For how long?
Did it help?

Treatment 5

Treatment
When was it tried?
For how long?
Did it help?

33. What do you think is the cause of your hair loss?

34. Is there any other important information you would like to share regarding your hair loss?

Disclaimer *

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