Medical Questionnaire

Full Name

Email address*

Contact Number

1. How long have you had hair loss?*

2. Since that time, how has your hair loss been? *

BETTER

WORSE

SAME

5. 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 hairbrush, etc.)?*

YES

6. Do you feel that your scalp hair is slowly thinning out over the top without losing excessive numbers of hairs daily?*

YES

7. Are your hairs *

BREAKING OFF

COMING OUT AT THE ROOTS

8. Within 6 months PRIOR to the onset of hair loss: Have you been started on any new medications?*

YES

a. If YES, please list

b. Have you had any hormone pills or birth control pills started or stopped?*

c. Any history of anemia or low iron? Are you on any treatment?*

YES

If, Yes please specify

d. Have you been experiencing any significant medical issues in your life, such as the birth of a child, surgery, illness, or hospitalization? *

e. Have you been experiencing any significant stress, such as divorce, family illness, cancer, or work issues?*

h. Have you had any recent weight loss or change in your diet?*

YES

If, Yes please specify

g. Do you have any infectious disease (such as influenza, measles, or tuberculosis) that is transmitted by contact?*

YES

9. Any history of anemia or low iron? Are you on any treatment?*

YES

If, Yes please specify

10. Any history of thyroid disorders? Are you on any treatment? *

YES

If, Yes please specify

11. Are you actively dieting?*

YES

If so, what type of diet?

12. Are you a vegetarian or vegan? *

YES

13. Have you had any recent lab work done to diagnose the hair loss?*

YES

Please include copies of any lab results.

14. Does your scalp itch or sometimes burn or hurt? *

YES

15. Do you have a rash or flaking in your scalp? *

YES

16. List any family members with hair loss or thinning hair (any grandparents, parents, or siblings)?

17. Please list all the prescription medications, supplements, and shampoos/solutions that you have tried for your hair loss.

18. 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.

19. 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.

This field should be left blank

MEDICAL QUESTIONNAIRE