Hair Loss Consultation Form

Name

First NameLast Name
Email
example@example.com
How long have you been experiencing hairloss?
More than 100About a 100I don't know its coming out in clumpsSlowly over time
Top/front of scalpSides of scalpBack of scalpEyebrowsEyelashesOther
History of Radiation
History of thyroid disease
History of Chemo Therapy?
History of crash dieting or rapid weight loss?
PsoriasisExcess facial hairSeborrheic dermatitisExcess body hair Discharge from breast Deepening of voice Polycystic ovary disease Do you have any divots/impressions/dots or ridges on your nails? History of Radiation History of thyroid diseaseDouble visionDischarge from breastCystic Acne Enlargement of clitorisDeepening of voiceEnlargement of clitorisPolycystic ovary diseaseDo you have any divots/impressions/dots or ridges on your nails?
History of Low levels of iron, zinc, and vitamin D?
Any use of low molecular weight heparin (and less commonly warfarin) medications?
History of autoimmune disease (please list)
In the last 3-12 months, have you experienced any of the following/

Please explain
Childbirth
High fever
Start or stop beta blocker medication
Severe infection
Start or stop birth control pills?
Start or stop hormone treatment?
Under severe psychological stress?
Flare of chronic illness
Major surgery
Prolonged illness or hospitalization
Any history of depression?
Have you recently dramatically changed your diet?
Do you see a rash in your scalp or on your face? If yes, please describe.
Are you on any type of hormone treatment? If YES, what type and for approximately how long?
Explain your history of hormone use
DadMomSiblingsGrandparentsOther
List all other doctors, their specialty, and when treated for this problem?
What lab tests were performed?
Was a biopsy performed?
Use of Minoxidil (Rogaine): Strength (2 or 5%)?Did it work?
LED light devices / helmets? Name
Ketoconazole shampoo? How long?
Steroid injections / Prednisone Use? Dose?
Other vitamins (list:)
Has any treatment helped more than others (explain)?
What is your occupation?
How severely has it affected your life?
Are you fearful of becoming bald?
MEDICATIONS ASSOCIATED WITH HAIR LOSS list any medications taken since you noticed hair loss.
What goals or expectations do you have for treatment?
Please bring any lab testing and biopsy results from the other doctors and their last office visit note to your visit.
Date

MonthDayYear
Date
Should be Empty:

In the last 3-12 months, have you experienced any of the following/