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Hair Loss Questionnaire

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Hair Loss Questionnaire

Skin Seriously.

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?
    • Lithium
    • Estrogen (birth control, hormone replacement)
    • Methotrexate
    • Valproic acid thyroid medication NSAIDS
    • Fluoxetine cholesterol lowering drugs chemotherapy
    • Warfarin diuretic blood pressure medications Enoxaparin steroids Parkinson’s meds
    • Metoprolol tamoxifen
    • Propranolol ACE inhibitors(lisinopril, captopril)
    • Isoniazid anti-seizure medications
    • Indinavir weight loss drugs
  • Do you or anyone in your family have: Hashimoto’s Thyroiditis, Pernicious Anemia. Vitiligo, Type I Diabetes
Contact Us Today

Have questions or concerns? Please call us at 610.558.1446

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