Pre-Consultation Hair Loss Questionnaire Questionnaire Before Consultation – To Show Your Practitioner Enter your email to receive this form filled in as a PDF to share with your doctor or practitioner: Email: We will not store your questionnaire and answers. Part 1: Essential Questions 1. Personal Information Sex: Male Female Age: Do you have a family history of hair loss? Yes No 2. Hair Loss Overview When did you first notice hair loss? Not sure, looking to prevent Within the last year Over a year ago How much hair have you lost? A little Some A lot Where are you noticing hair loss? No visible loss Along the hairline Hairline and crown Crown, temples, and forehead All over the top Little to no hair left Would you like to take a quick online hair health assessment using an AI picture system? Yes No Do you know the cause of your hair loss? Age Hereditary Stress Illness or hair condition Medications Don’t know Do you notice excessive shedding in these situations? When brushing/combing When shampooing On clothes throughout the day After sleeping No excessive shedding 3. Scalp & Hair Condition Do you have a sensitive scalp? (Does it hurt during brushing or when using scalp massage tools?) Yes No How would you describe your scalp? Dry Medium/mixed Oily How would you describe your hair density? High (scalp not visible) Medium (some scalp visible) Low (more scalp than hair visible) 4. Hair Care Routine How often do you wash your hair? Daily Every 2 days Twice a week or less What shampoo do you use? (Brand & Product Name) Do you use a conditioner? Yes No If yes, which one? Do you use any hair & scalp treatments (e.g., oils, serums, scalp masks)? Yes No If yes, specify: Do you use very hot water to wash your hair? Yes No (Regular temperature) Do you have a water filter on your shower? Yes No Which city do you live in? (for water quality assessment) 5. Treatments & Goals What treatments have you tried? Topical treatments (e.g., Minoxidil, medicated shampoo) Oral supplements Laser therapy Hair replacement Hair transplant None of the above Other If other, please specify: What is your primary goal for treatment? Stop hair loss Increase hair density Improve hair thickness Strengthen fragile hair Part 2: Extended Questions 6. Medical & Lifestyle Factors Have you been diagnosed with any of the following conditions? Thyroid disorders Anemia Autoimmune diseases (e.g., alopecia areata, lupus) PCOS (for women) Cancer (current or past) Chronic illnesses (e.g., diabetes, hypertension) None of the above Have you undergone chemotherapy or radiation therapy? Yes No Are you currently taking any medications? Yes No If yes, please specify: Have you taken a nutrients, vitamins, or minerals deficiency test? Yes No Would you like to do one specifically for hair health? Yes No Have you experienced recent weight loss or drastic diet changes? Yes No Have you been pregnant in the last 12 months? Yes No Do you experience high levels of stress? No Occasionally Frequently 7. Hair & Scalp Health How would you describe your hair type? Fine Medium Thick How would you describe your hair texture? Straight Wavy Curly Afro If you answered Medium or Low for density, when did you first notice a reduction in hair density? Less than 6 months ago 6–12 months ago 1–3 years ago More than 3 years ago Have you noticed any of the following scalp issues? Itching Redness Dandruff Oily/greasy scalp None Have you been using any shampoos or treatments for these issues? Yes No If yes, what is the name of the product? 8. Hair Care & Styling Habits Do you swim regularly in chlorinated pools or the sea? Yes No Do you style your hair with heat tools? No Blow dry (normal temperature) Blow dry (very hot air) Straightener or curling iron Do you use styling products? Hairspray Gel Wax Mousse None 9. Final Treatment Preferences Would you like to take an online assessment of your hair health and density? Yes No Are you open to medical treatments (e.g., Minoxidil, Finasteride, PRP)? Yes No Are you considering a hair transplant? Yes No Submit
