Dermatology Institute

Bill V. Way, D.O.

706 W. Center St. Duncanville, Tx. 75116

Confidential Hair Loss Questionnaire

 

Name:†††††††††††††††††††††††††††††††††††††††† †††††††††††††††D.O.B.††††††††††††† ††Age:†††† ††††Sex:††††† Date:

 

1.†† Losing hair for less than 1-3 months, 3-6 months or 6 months?†† Circle Location:†† Scalp†††††† Body†††††† Other

†††††††††††††††††††††††††††††††††††††††††††††††††††

2.††† Do you sleep in curlers?___ YES†† ___NO

††††††††††††††††††††††††††††††††††††††††††††††††††††††††

3.††† Do you take Vitamin Supplements?___ YES†† ___NO

††††††††††††††††††††††††††††††††††††††

4.         Does your hair grow to your satisfaction? ___ YES†† ___NO

†††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††††††††††††††††††

5.       Are you taking any medications?†† ___ YES†† ___NO†† If so, please list all; especially include aspirin, laxative etc.

6.       ††Have you recently lost any weight?††† ___ YES†† ___NO††How much?

 

7.       ††Have you recently gained any weight?††† ___ YES†† ___NO††† How much?

 

8.       ††Are you on any special diet?___ YES†† ___NO†† If so, what kind?

 

9.       ††Have your periods recently changed? ___ YES†† ___NO†††† If yes, describe fully, more or less flow, etc.

 

10.    †††Do you have any excess hair on your body? ___ YES†† ___NO††† If yes, where?

 

†††††† ††††Breast††† Face††† Upper thigh††† Upper lip†† Abdomen

†††††† ††††Have you recently grown hair on any of the above sites?

 

11.                Have you recently become more nervous? ___ YES ___NOAre you nervous when there is no apparent reason?

 

12.                Any history of thyroid disease in your family? ___ YES†† ___NO

 

13.                Any history of hair loss in females in your family? †††___ YES†† ___NO†† If yes,

†††††††††† Please list if motherís or fatherís side and describe pattern.

 

14.                Any history of hair loss in males in our family? ___ YES†† ___NO If yes, please list if

†††††††††† motherís or fatherís side and describe pattern.

 

15.                Have you recently had a baby?††† ___ YES†† ___NO††† If yes, how old is your baby?

 

16.                Do you go to a Beauty Salon?††† ___ YES†† ___NO†††† If yes, how often?

 

†††††††††† Once a week††††† Twice a week††††† Three times a month†††††† other

 

17.                Do you roll your hair in rollers? ___ YES†† ___NOEvery night or how often

18.                 

19.                Do you roll your hair in brush rollers? ___ YES ††___NO†† If yes, how often?

 

20.                Do you put your hair in rubber bands? ___ YES†† ___NOIn a ponytail?

 

 

 

 

 

 

 

 

 

 

 

Name:†††††††† ††††††††††††††††††††††††††††††††††††††††††††††D.O.B.†††††††††††††† Age:†††††† ††Sex:††††† ††Date:

 

21.                Do you use hair spray? ___ YES†† ___NOIf yes, how often and how much?

 

22.                Do you bleach or color your hair? ___ YES†† ___NO†† If yes, how often?

 

23.                Do you tease your hair? ___ YES†† ___NO††† If so, describe where and how often?

 

24.                Do you brush your hair with a nylon brush? ___ YES†† ___NO†† If yes, how often?

 

25.                Are you on birth control pills or hormone supplement medication? ___ YES†† ___NO If yes, which one and how long?

 

26.                Did you lose hair while on the birth control pills?___ YES†† ___NO†† How many months?

 

27.                Are your nails breaking? ___ YES†† ___NO

 

28.                Did you shed hair after your pregnancy? ___ YES†† ___NO

 

29.                Is your skin dry? †††___ YES†† ___NO†††††††††Has your skin changed recently? ___ YES†† ___NO

 

30.                Have you had any other symptoms lately? ___ YES†† ___NO If yes, please list. Examples: Nausea, Excess Fatigue?

 

31.                Have you been ill recently?___ YES†† ___NO†† Did you have high temperature?___ YES†† ___NO†† How High?

 

32.                Have you had a recent operation?___ YES†† ___NO†††††† When?

 

33.                Have you been under severe emotional strain lately? ††___ YES†† ___NO††††††If yes, how long?

 

34.                How often do you shampoo your scalp hair?

35.                 

36.                What is your usual shampoo?

 

37.                Did your maternal or paternal mother or grandmother have thin hair when they reached older age? ___ YES†† ___NO††††††††††††††††††††††††††† If so, what age did this start? ††††† Father or Grandfather?††††††† ††††††† ††††††If so, what age?

 

38.                How long do you stay under the hair dryer?††††††††††††††††††††† How frequently?

 

39.                Do you use a hair straightener? ___ YES†† ___NO

 

40.                Do you ever use cold wave solution? ___ YES†† ___NO ††††If yes, how often?

 

41.                Have you had a recent permanent?___ YES†† ___NO†††††††† When?

 

42.                Is your hair brittle on the ends? ___ YES†† ___NO

 

43.                Have you been exposed to any chemical such as fertilizer, spray, and insecticides, etc. inhaled or contact with body? ___ YES†† ___NO

44.                Do you eat fish weekly or more often?

 

45.                Have you had any scaling areas in your scalp? ___ YES†† ___NO

 

46.                Do you have any areas of complete hair loss in scalp?___ YES†† ___NO††††††††††††††††††