Please complete the Alopecia Questionnaire before your appointment.

    Was onset of hair loss sudden or gradual?

    Is your hair thinning or is it shedding?

    Do you use:

    If you have a weave, is it sewn or glued?

    Do you use hot combs, press and curl, curling irons or otherwise apply direct heat to your hair?

    dye?

    Is it a relaxer that contains lye?

    Do you have a permanent wave?

    Does you scalp itch?
    LittleModerateA lot

    Do you get sores in your scalp?

    Do you have seborrheic dermatitis?

    Do you have psoriasis?

    What medications are you allergic to?

    Do you use herbs or supplements?

    Are you are on birth control pills?

    Have you recently started?

    Or stopped taking birth control pills?

    Or did you stop taking hormones?

    If applicable, are your menstrual periods regular?

    Normal Flow?

    Have you gone through menopause?

    Are you on any type of weight loss diet?

    Are you on a low protein diet?

    Any hair loss in men in your family?

    Baldness?

    Any hair loss in women in your family?

    Thinning?

    Do you have?

    Select all that apply
    Severe headachesDouble visionExcessive facial hairCystic acneDischarge from breastDeepening of your voiceEnlargement of clitorisPolycystic ovary disease

    Have you had in the last 3-12 months?

    Select all that apply
    High feverChildbirthSevere infectionFlare of chronic illnessMajor surgeryOver or under active thyroidLow protein dietLow iron in bloodSevere psychological stressStart or stop birth control pillsStart or stop hormone treatmentStart or stop beta blocker medication

    Do you see a rash in your scalp or on your face?