Hair loss investigation
This questionnaire is meant to identify many of the common causes of hair loss that I have observed in clients over my decades as a hairdresser. While it can be a helpful tool when paired with professional medical guidance, it should never replace or contradict the personalized advice of your doctor.
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Trans Woman
Trans Man
Cis Woman
Cis Man
Non-Binary (assigned Male at birth)
Non- Binary (assigned Female at birth)
Other
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Have you recently (past 2 years) changed your diet in any of these ways ( check all that apply):
Vegetarian
Vegan
Calorie reduction
Elimination diet
Diet change due to Ozembic (or other)
Diet Change due to weigh loss surgery
Diet restriction around dairy and meat
Low Fodmap Diet
Food allergies
Cleanse by reducing calories for a specific time-frame
Other
Have your hormone levels changed in the past 2 years? ( Check all that apply)
Entered Perimenopause
Went on birth control pills
Went off birth control pills
Went on HRT (hormone replacement therapy)
Went off HRT
Got pregnant
Gave Birth
Entered Menopause
Experienced Weight loss
Have a history of thyroid problems in your immediate family
Other
Have you used any of these Hair products in past 2 years? ( Check all that apply)
Olaplex
Wen by Chaz Dean
Deva Curl “no poo” products
TRESemmé Keratin Smooth
OGX (Johnson &Johnson)
Suave Professionals Keratin
Monat
Selsun Blue Max Strength
How is your scalp health? Experience any of the following: ( Check all that apply)
Dandruff dry
Dandruff waxy
Psoriasis/ Eczema
Clogged pores/ scalp acne
trichotillomania (hair pulling -OCD)
Scars that won’t grow hair
Extreme sensitivity
Effects of Chemotherapy or other medical treatments
New or Irregular shaped moles
Feeling a tightness to the scalp
Have you experienced a new medication or medical condition that is known to affect your hormones ? Ex: Thyroid conditions , COVID-19 etc
Yes
No
Please rate your stress level before and during the hair-loss
The most possible stress available
Pretty dang crazy high
Medium but notable
kinda low but still around
Pretty low actually namaste
Do you have any first degree family members experiencing hair loss?
Please Select
Yes
No
If you feel comfortable sharing these relatives experience it can be helpful to your journey.
Are you experiencing higher than average inflammation or allergies?
Please Select
Yes
No
Don’t know
Other
Are you currently taking any vitamins or supplements?
In your own words how can we help you with this difficult situation? Some common options include: Discuss non clinical causes of hair loss typically related to lifestyle. Design you a haircut to help blend the loss, add extensions, or discuss custom made and measured hair pieces.
Submit
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