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