Answer the following questions to tell us more about your hair loss condition.

For some questions, please check YES or NO in the box at the right. For other questions, please write your answers in the space provided.

Your Information

Sex at Birth *

Female

Male

Other

What did you notice at that time? *

hair “coming out” or shedding

hair looked thinner on scalp

Have you recently noticed that your hair loss was worsening? *

Yes

Hair Loss Background

What makes you think it is worsening? *

Please check the box that best describes your family members’ scalp hair (If you have more than one brother or sister, mark the box that describes the brother or sister who has the least amount of hair):

Has a lot of hair

Father

Mother

Brother

Sister

Has a small bald area

Father

Mother

Brother

Sister

Has some thinning

Father

Mother

Brother

Sister

Has a large bald area

Father

Mother

Brother

Sister

Has (or had) many bald spots

Father

Mother

Brother

Sister

Health Information

Have you been under a severe amount of stress at any time before or during the hair loss? *

Yes

Are you a vegetarian? *

Yes

Have you been hospitalized at any time before or during the hair loss? *

Yes

If yes, when did you begin to notice it was worsening?

Have you had a serious illness at any time before or during the hair loss? *

Yes

If yes, please describe the illness and state when it occurred

Have you started any special diets at any time before or during the hair loss? *

Yes

If yes, when did it start and end?

Please list the names of all the medications you are currently taking in the space below.

1
2
3
4
5

If yes, why were you hospitalized and when did you leave the hospital?

Have you ever been told by a doctor that you have a low iron level?

Yes

Have you ever been told by a doctor that you have a thyroid condition?

Yes

Have you ever been treated with thyroid hormone? *

Yes

Please list any vitamins or natural products that you are taking:

1
2
3
4
5

Are you menopausal?

Yes

If you are menopausal, when did menopause occur?

If you are not menopausal, do you get your menstrual period every month?

Yes

Have you been pregnant at any time before or during the hair loss?

Yes

If yes, when did the pregnancy end?

Have you ever needed to take birth control pills to make your periods regular?

Yes

Do you have unwanted or excessive hair growth on your body?

Yes

If Yes, Where is the unwanted/excessive hair growth located?

Lifestyle Information

How often do you wash/shampoo your hair? *

How often is your hair heat processed or straightened (e.g. blowdrying/ flat ironing, curling iron)? *

How often is your hair chemically processed or straightened (relaxers, Japanese straightening, other)? *

How often is your hair dyed, highlighted or otherwise color treated? *

Please check all hair styling practices that you have done in the past

Braiding

Weaves

Tight hairstyles (e.g. ponytails)

Do you have symptoms on the scalp (e.g. itching, pain, burning)? *

Yes

Where on the scalp do the symptoms occur?

The top

The sides

The back

The temples

What do you think is the cause of your hair loss? *

Is there any other important information you would like to share regarding your hair loss?