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 †___NO† Are 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†† ___NO† Every night or how often
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†† ___NO† †In a ponytail?
Name:†††††††† ††††††††††††††††††††††††††††††††††††††††††††††D.O.B.†††††††††††††† Age:†††††† ††Sex:††††† ††Date:
21. Do you use hair spray? ___ YES†† ___NO† †If 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? †
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† ††††††††††††††††††