Hair By Hospitalia

Questionnaire responses, medical records and any other data provided will be kept strictly confidential, ensuring your privacy.

Hair Loss Questionnaire

Patient's Information

Name
Name
First
Middle
Last
Marital Status:

Emergency Contact Information

Name
Name
First
Last

Hair Loss History

My condition is:
Which part of your head has hair loss?

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)?
Do you feel that your scalp hair is slowly thinning out over the top without losing excessive numbers of hairs daily?
Are your hairs
Do you noticed hair regrowth since the onset of alopecia?

Within 6 months PRIOR to the onset of hair loss:

Have you been started on any new medications?
Have you had any 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, moving, family illness or cancer, or work issues?
Have you had any recent weight loss or change in your diet?
Does your scalp itch or sometimes burn or hurt?
Do you have a rash or flaking in your scalp?
How often is your hair colored, chemically processed, or straightened?
Do you comb your hair?
Which do you use?
Do you use a hair dryer?
What type of hair care products do you use?
How do you wear your hair?
Do you cover your hair?
Do you pull your hair when you are anxious or under stress?

For Women Only

Are your periods
Do you have excessive hair?
Have you had difficulty becoming pregnant?
Are you postmenopausal?
Have you had a hysterectomy?
Have your ovaries been removed?

Family History Of Hair Loss

From which side of the family?
Which member?

Your Hair Restoration History

I had the following hair restoration procedures:

Medical History

Any history of anemia or low iron?
Are you on any treatment?
Any history of thyroid disorders?
Are you on any treatment?
Are you actively dieting?
Are you a vegetarian or vegan?
Have you had any recent lab work done to diagnose the hair loss?

Maximum file size: 3MB

Are you suffering from any acute infectious process?
Did you undergo any surgery?
Do you have scars?
How do you consider your healing?
Do you suffer or did you suffer from any of the following pathologies?
Which chronic conditions do you have?
Autoimmune?
Dermatologic disorders?