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Hair Loss Questionnaire
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Name
*
Data
*
How long have you had hair loss?
Since that time, how has your hair loss been?
Better
Worse
Same
Which part of your head has hair loss?
All Over Front
Hairline Crown Back
Lower
Other
How rapid was/is the hair loss?
Sudden
Gradual
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)?
Yes
No
Do you feel that your scalp hair is slowly thinning out over the top without losing excessive numbers of hairs daily?
Yes
No
Are your hairs?
Breaking Off
Comming Out At The Roots
within 6 months PRIOR to the onset of hair loss: Have you been started on any new medications?
Yes
No
If Yes, Please List
Do you take any daily Vitamins Yes Or No What kind
Have you had any medications or 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?
Have you been experiencing any significant stress, such as divorce, family illness or cancer, or work issues?
Have you had any recent weight loss or change in your diet?
Any history of anemia or low iron?
Yes
No
Are you on any treatment?
Any history of thyroid disorders?
Yes
No
Are you on any treatment?
Are you actively dieting?
Yes
No
If yes, what type of diet?
Are you a vegetarian or vegan?
Yes
No
Have you had any recent lab work done to diagnose the hair loss or a recent complete chemistry blood work within 18 months?
Yes
No
Does your scalp itch or sometimes burn or hurt?
Yes
No
Do you have a rash or flaking in your scalp?
Yes
No
List any family members with hair loss or thinning hair (any grandparents, parents, or siblings)?
Please list all the prescription medications, supplements, and shampoos/solutions that you have tried for your hair loss: Treatment When was it tried? For how long? Did it help?
Please list the names and dosages of all medications, over-the-counter pills, and hormone pills that you are currently taking and circle 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 circle 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:
Regular
Irregular
Do you have excessive hair on your chin, face, chest?
Yes
No
Are you postmenopausal?
Yes
No
At what age?
Have you had recent surgery?
Yes
No
When?
Have you had a hysterectomy?
If yes When
What do you think is the cause of your hair loss? Or, any possible contributing factors?
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