Hair Loss Questionnaire


A hair loss questionnaire is used to access the hair loss condition of any individual suffering from any sort of hair issues. These questionnaires are used by various medical institutions and hair loss treatment manufacturers.

Sample Hair Loss Questionnaire

Name:

Age:

Gender:

Contact No.:

Answer the following questions:

1. What kind of scalp do you have i.e. scalp skin type?

a. Dry

b. Oily

c. Normal

d. ________________, specify if any other

2. Have you been experiencing excessive shedding of your hair? (In the shower, pillows, bath tubes etc.; shedding means excessive hairs falling out daily)

a. Yes

b. No

c. _________________, specify if any other like moderate

3. Have you been experiencing slow thinning out of your scalp hair even without losing excessive number of hairs daily?

a. Yes

b. No

c. Somewhat

4. Are you losing your hair :

a. In patches (i.e. patches of hair falling out)

b. Diffusely (i.e. evenly over the whole scalp)

c. Noticeably on certain parts of scalp, ________________ (specify where)

5. Are your hair breaking off or are they coming out of the scalp with the roots (white club at the end) attached?

______________________________________________________________

6. Provide an approximate time since when you have been noticing these hair problems you specified above or the time you first noticed them.

______________________________________________________________

7. Are you losing hair elsewhere?

________________________________________________________________

8. Do you have any family history of male patterned baldness or females with history of thinning? Any history of patchy loss here? Specify.

_________________________________________________________________

9. Kindly specify if you have any or there is a family history of allergies for example hay fever or eczema etc.

_________________________________________________________________

10. Kindly specify if you have any other past or present medical conditions. Include the dates of beginning of each.

_________________________________________________________________

11. Kindly provide a list of medications you are taking (if any).

_________________________________________________________________

12. Kindly give a brief of your daily diet.

_________________________________________________________________

 

Category: Fashion Questionnaire

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