Hair Loss Questionnaire

Duration of hair loss? Have you noticed gradual or sudden thinning?

Have you noticed active hair shedding? (excessive hairs on pillow, while combing or shampooing)

Pattern of hair loss: (generalized localized to specific areas)

Does your hair break?

Symptoms: itching, burning, pain

Have you recently been hospitalized?

Have you recently experienced a stressful event? (divorce, death of a loved one, family or personal illness, moving, change in job, unemployment)

Have you recently lost weight? If yes, how much?

Do you eat red meat?

Are you vegetarian/vegan?

Do you or anyone in your family have celiac disease?

Have you been pregnant recently?

Are you menopausal, perimenopausal? (night sweats, hot flashes, irregular periods)

Do you have regular periods? Do you have excessive bleeding during your period?

Do you have excess hair growth in other areas of your body?

What hair care products do you use?

How do you style your hair?  Straightening, permanent wave, braiding?

Do you have a family history of hair loss? In whom?

Have you begun any new medications?

Do you or have you taken any of these medications?