Hairloss Questionnaire

Date

Name

DOB

Race

Height

Weight

When did you last have a normal head of hair?

Was the onset of hair loss sudden or gradual?

Is your hair coming out “by the roots” or is it breaking off?

Is your hair thinning or is it shedding?

How often do you wash your hair?

What hair products do you use?

Do you use hot rollers, ponytails, braids, twists, locks, extensions, or weaves?

Yes No

How long do you leave hot rollers, ponytails, braids, twists, locks, extensions, or weaves installed for?

How often do you do hot rollers, ponytails, braids, twists, locks, extensions, or weaves?

Do you use hot combs, press and curl, curling irons or otherwise apply direct heat to your hair?

What type of hair chemicals do you use for your hair?

Is it a relaxer that contains lye?

Yes No

Do you have a permanent wave?

Yes No

How long?

How often do you straighten your hair?

Does your scalp itch?

Little Moderate A LOt

Do you get sores in your scalp?

Yes No

Do you have seborrheic dermatitis?

Yes No

Do you have Psoriasis?

Yes No

What medications are you allergic to?

What medications do you take?

Do you use herbs or supplements?

Yes No

Provide the herb or supplement names

If you are on birth control pills, which one?

Have you recently started?

Yes No

When did you start?

Or have you stopped your birth control pills?

Yes No

When did you stop?

Are you on any other type of hormone treatment?

Yes No

Which one?

How long?

Are you on any other type of hormone treatment?

Yes No

When did you stop?

If applicable, are your menstrual periods regular?

Yes No

Normal flow?

Yes No

Have you gone through menopause?

Yes No

Age

Are you on any type of weight loss diet?*

Yes No

Are you on a low protein diet?

Yes No

Are you a vegetarian? if so what type?

Any hair loss in men in your family?

Yes No

Baldness?

Yes No

Any hair loss in women in your family?

Yes No

How thin?

Any family history of thyroid disease, anemia, or lupus?

What medical problems do you have?

Do you have any of the following?

Have you had in the last 3-12 months?

Do you see a rash in your scalp or on your face? If yes, please describe.

Treatments previously tried? (Rogaine, Vitamins, Shampoos, etc.)

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Hairloss Questionnaire

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