Hair Loss Intake Questionnaire

Hair Loss Intake Questionnaire

Please complete this questionnaire about your hair loss, medical history, hair care, symptoms, and treatment goals.
Patient Information and Hair Loss History
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What type of hair loss are you experiencing?
Other type of hair loss
When did the hair loss begin?
How quickly did it start?
Has it been?
Location of hair loss — check all that apply
Has anyone in your family experienced hair loss?
Relationship and age of onset
Triggers and Medical History
Recent triggers in the last 12 months

Other
Please explain recent triggers
Do you have a history of:

Other
Other medical conditions
Have you started, stopped, or changed any medications within the past year?
Current medications
Current supplements
Have you used any hair-loss treatments?

Other
Other hair-loss treatment
Women-Only Questions
Are you?
Are your periods:
Do you have:
Current contraception
Are you pregnant?
Are you breastfeeding?
Men-Only Questions
Men only — Have you noticed any of the following?

Other
Other men-only observation
Hair Care, Scalp, Diet, and Symptoms
How often do you wash your hair?
Other hair-washing frequency
Do you regularly use any of the following?
Scalp symptoms — check all that apply
Have you followed any of these diets in the last year?
Other diet
Daily protein intake
Check any symptoms you currently have
Treatment Goals and Consent
Treatment Goals

Other
Other Treatment Goals
Photo Consent
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Hair Loss Intake Questionnaire

Patient Information and Hair Loss History

Triggers and Medical History

Women-Only Questions

Men-Only Questions

Hair Care, Scalp, Diet, and Symptoms

Treatment Goals and Consent