Hair Loss QuestionnaireElizabeth Rostan, M.D.

Hair Loss Questionnaire

Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle, and skin concerns; thereby enabling the best treatment plan to be customized for your individual needs.

Name

First Last

Hair Loss History

How long have you had hair loss?

Have you had any previous treatments for hair loss? (Please list or describe previous treatments)

Since that time, how has your hair loss been?

Better

Worse

Same

In what areas have you been experiencing hair loss? Please check all that apply:

All Over

Front/Hairline

Crown

Back/lower

Sides

Other

How rapid was the hair loss?

Sudden

Gradual

Shedding is defined as having excessive numbers of hair strands falling out daily.

Thinning is defined as having less hair to cover the scalp, with or without excessive hair strands lost each day.

Do you feel that you have been shedding excessive numbers of hairs (in the shower, on your hairbrush, etc.)?

Yes

Do you feel that you scalp hair is slowly thinning out over the top without losing excessive number of hair strands daily?

Yes

Are you hair strands

Breaking Off

Coming out at the roots

Within 6 months PRIOR to the onset of hair loss:

Have you been started on any new medications?

Yes

If Yes, please list

Have you had any of the following with 6 months prior? Check all that apply:

Change to hormone pills or birth control

illness

Surgery

Weight loss

Pregnant or breastfeeding

Signification Stress

Hospitalization

Blood test / if yes, any abnormal?

Yes

Any family history of hair loss?

Yes

If yes, who?

Any history of flaking or itching of scalp?

Yes

Any history of anemia or low iron?

Yes

Are you on any Treatment?

Any history of thyroid disorders?

Yes

Are you on any Treatment?

Any history of stress, anxiety, or depression?

Yes

Do you have a special diet?

Yes

if so, what type of diet?

Hair Care History

How often is your hair colored, chemically processed, or straightened?

Never

Do you wear your hair in tight braids?

Yes

If yes, how recently and how often?

Female Patients

Are your periods

Regular

Irregular

Do you have excessive hair?

Chin

Face

Abdomen

Around Nipples

Are you on hormones – replacement therapy?

Yes

Are you postmenopausal?

Yes

At what age?

Have you had a hysterectomy?

Yes

When?

Have your ovaries been removed?

Yes

When?

Request an Appointment

Schedule Your

Appointment

704-333-9113

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Thursday 8AM–5PM
Friday 8AM–4PM
*Saturday Closed
Sunday Closed
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Charlotte Skin and Laser 130 Providence Road Charlotte, NC 28207

Phone: 704-333-9113
Fax: 704-333-9757
Email: Contact Form