Hair Loss Questionnaire

Date

MonthDayYear
Date
Hair Loss Questionnaire
Contact Number
Email Address
example@example.com
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.
Full Name

First NameLast Name
When did you FIRST notice that you were losing your hair? What did you notice at that time?
Have you recently noticed that your hair loss was worsening?

YesNo
If yes, when did you begin to notice it was worsening?What makes you think it is worsening?

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):has a lot has some has a small has a large has (or had) of hair thinning bald area bald area many bald spots

	Has a lot	Has some	Has small	Has large
Father
Mother
Brother
Sister

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

YesNo
If yes, when did the pregnancy end?
Have you had a serious illness at any time before or during the hair loss?

YesNo
If yes, please describe the illness and state when it occurred
Have you been hospitalized at any time before or during the hair loss?

YesNo
If yes, why were you hospitalized and when did you leave the hospital?
Have you been under a severe amount of stress at any time before or during the hair loss?

YesNo
If yes, when did it start and end?
Have you started any special diets at any time before or during the hair loss?

YesNo
Are you vegetarian?

YesNo
Please list the names of all the medications you are currently taking in the space below
Please list any additional medications that you were taking when your hair began to fall out that you are no longer taking
Please list any vitamins or natural products that youare taking
Are you menopausal?

YesNo
If you are menopausal, when did menopause occur?
If you are menopausal, were your periods (menses) regular prior to menopause?

YesNo
If you are not menopausal, do you get your menstrualperiod every month?

YesNo
If yes how often does your period come? every ______ days a month
Have you ever needed to take birth control pills to make your periods regular?

YesNo
Do you have unwanted or excessive hair growth on your body?

YesNo
Where is the unwanted/excessive hair growth located?
Do you have hair loss anywhere else on your body?

YesNo
Where (other than the scalp) is the hair loss located?
Do you have any abnormal fingernails or toenails?

YesNo
How often do you wash/shampoo your hair? every ______ days
How often is your hair chemically processed or straightened (relaxers, Japanese straightening, other)?

NeverOnce a weekOnce every 2 – 3 weeksOnce every 1 – 2monthsA few times a year
How often is your hair heat processed or straightened (e.g. blowdrying/ flat ironing, curling iron)?

NeverOnce a weekOnce every 2 – 3 weeksOnce every 1 – 2monthsA few times a year
Please check all hair styling practices that you have done in the past

BraidingWeavesTight Hairstyles (e.g.ponytails)Other
If other, please specify
Have you had a biopsy of your scalp to evaluate your hair loss problem?

YesNo
Have you had blood tests done to evaluate your hair loss problem?

YesNo
What tests were done?
Have your hormones ever been checked to evaluate your hair loss problem?

YesNo
If yes, when? What was the result?
Have you ever been told by a doctor that you have a thyroid condition?

YesNo
Have you ever been treated with thyroid hormone?

YesNo
When?
Have you ever been told by a doctor that you have a low iron level?

YesNo
When?
Do you (or a family member) have any autoimmune diseases?

YesNo

Check all that apply:

	Self	Family Member
Lupus
Rheumatoid Arthritis
Celiac disease
Type 1 diabetes
Sjogrens disease
Vitiligo
Other

If other, please specify
Do you have symptoms on the scalp (e.g. itching, pain, burning)?

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

ItchingTendernessPainBurningOther
If other please specify
Where on the scalp do the symptoms occur?

The TopThe SidesThe backThe TemplesOther
If other please specify
Please list all the prescription and non-prescription treatments that youhave tried for your hair loss condition:
Treatment When was it tried? For how long? Did it help?
What do you think is the cause of your hair loss?
Should be Empty: