• Quality Dermatology

  • Hair Loss Pattern and Onset

  • Type of hair loss experienced*
  • When did hair loss begin?*
  • How quickly did hair loss start?*
  • Hair loss progression*
  • Location of hair loss*
  • Family members with hair loss

  • Triggers, Medical History, and Medications

  • Recent triggers in the past 12 months
  • Medical history
  • Started, stopped, or changed any medications in the past year?*
  • Hair loss treatments used

  • Women Only Section

  • Menopausal Status*
  • Periods*
  • Related Symptoms or Conditions
  • Pregnant or Breastfeeding*

  • Men Only Section

  • Noticed changes*

  • Hair Care, Scalp, Diet, Symptoms, Goals, and Consent

  • Hair washing frequency*
  • Regular hair-care practices
  • Scalp symptoms
  • Diets or weight-loss methods followed in the last year
  • Daily protein intake
  • Current symptoms
  • Treatment goals
  • Photo consent*
  • Date and time*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: