HAIR LOSS QUESTIONNAIRE

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Hair loss generally falls into one of the following categories, Diffuse Thinning, Diffuse Shedding or Patchy Loss.

Diffuse Shedding is defined as having excessive numbers of hairs falling out daily.

Diffuse Thinning is defined as having less hair to cover your scalp, with or without excessive hairs lost each day.

Patchy Loss is defined as having round or irregular areas of total hair loss, scalp or other hair-except male pattern baldness.

Please fill in ONLY ONE FORM based on your hair loss category. FORM 1 for Diffuse Shedding or Diffuse Thinning and FORM 2 for Patchy Loss

FORM 1: Diffuse Shedding or Diffuse Thinning

FORM 2: Patchy Loss

Name

First Name

Last Name

Phone

(###)

###

####

They’re several types of hair loss occurring in round or extensive irregular patches, usually on the scalp. Answers to the following questions will assist us in learning more about your type of hair loss.

What is your ethnic or racial group?

Age of onset

When first patch was noticed

Duration of hair loss

Duration of current episode

Number of episodes of hair loss, assuming your hair regrew fully in between each episode

What methods of treatments have you had, and how did your hair loss respond?

What is the most extensive hair loss you have ever experienced?

Is hair being actively lost at present?

What sites on your body are affected by hair loss?

Please include all that apply

Scalp Only

Eyelashes

Eyebrows

Pubic Area

Auxiliary

Extremities

Beard in men

Are your fingernails normal?

Do you have unusual skin eruptions?

Do you or anyone in your family have a history of asthma, eczema or hay fever?

Do you or anyone in your family have any autoimmune diseases?

Such as pigment loss (veiling), thyroid disease, lupus, rheumatoid arthritis, scleroderma (hardening of the skin), or insulin-dependent diabetes

Do you have any idea what triggers the hair loss episodes such as stress, infection, etc?

What drugs were you taking when your hair loss began?

Any seasonal variation?

Do you experience itching or tingling of your scalp when hair loss is active?

Is there scaling, redness, pustules or roughness associated with the areas of hair loss?

If you have additional insight into your hair loss that you would like to include in this questionnaire, please use the space below for comments.

HAIR LOSS QUESTIONNAIRE

CONTACT

ESET MD

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