Hair Loss Questionnaire

First and Last Name: *

Age: *

Gender: *

Email Address: *

How long have you had hair loss? *

Which part of your head has hair loss? *

Since that time, your hair loss is: *

How rapid was the hair loss? *

Are your hairs (check one): *

Shedding is defined as having excessive numbers of hairs falling out daily. Thinning is defined as having less hair to cover the scalp, with or without excessive hairs lost each day. Do you feel that you have been shedding excessive numbers of hairs (in the shower, on your hair brush, etc)? *

Do you feel that your hair/scalp is slowly thinning out over the top without losing excessive numbers of hairs daily? *

Are you actively dieting? *

If YES, please specify.

Are you a vegetarian or vegan? *

Have you had any recent lab work done to diagnose the hair loss? *

Does your scalp itch or sometimes burn or hurt? *

Do you have any scar, rash or flaking on your scalp? *

If YES, please specify.

List any family members with hair loss or thinning hair (any grandparents, parents, or siblings)? *

Please list all prescription medications, supplements, and shampoos/solutions that you have tried for your hair loss: *

Did any of the solutions in the previous question help?

If YES, please specify.

What shampoo/topical are you currently using? *

Please list the names and dosages of all medications, over-the-counter pills, and hormone pills that you are currently taking and specify the ones that you were taking when your hair began to fall out. *

Please list the names and dosages of all vitamins and natural supplements that you are taking and specify the ones that you were taking when your hair began to fall out: *

How often is your hair colored, chemically processed, or straightened? *

(For Women) Are your periods:

(For Women) Are you postmenopausal?

If YES, at what age?

Within 6 months PRIOR to the onset of hair loss: Have you started on any new medications? *

If YES, please list:

Have you had any hormone pills or birth control pills (started or stopped)? *

Have you been experiencing any significant medical issues in your life, such as the birth of a child, surgery, illness, or hospitalization? Please be specific. *

Have you been experiencing any significant stress, such as divorce, family illness or cancer, or work issues? Please be specific. *

Have you had any recent weight loss or change in your diet? Please be specific. *

Any history of anemia or low iron? *

If YES, please specify.

Any history of thyroid disorders? *

If YES, please specify.

What do you think is the cause of your hair loss? Or, any possible contributing factors? *