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* 1. What is your Name or Health Card number

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* 2. Are you interested in any of the following?

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* 3. How long ago did you notice your hair loss?

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* 4. Do you look different than 6 months ago? (re: hair loss)

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* 5. Have you ever had a scalp biopsy?

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* 6. Where on the scalp do you feel you have lost hair? (select all that apply)

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* 7. Is your hair loss in a specific area/spot or all over?

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* 8. Have you tried ANY type of treatment yet for your hair loss (topical medicines, prescription medications, shampoos)?

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* 9. Have you ever had steroid injections into the scalp or area of hair loss?

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* 10. Do you use any of the following?

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* 11. Do you dye your hair?

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* 12. Do you have any grey hair?

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* 13. Do you get itchy scalp?

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* 14. How oily do you feel your scalp is?

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* 15. Do you get burning or tingling of the scalp?

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* 16. Does your scalp ever feel tender or sore?

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* 17. Do you get dandruff?

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* 18. Is your hair shedding more than usual?

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* 19. Do you get redness or rash on your scalp?

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* 20. How often do you shampoo your hair?

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* 21. Have you changes shampoos in the last month?

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* 22. What shampoo do you use?

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* 23. Do you get rashes on any of the following places?

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* 24. DO you have any allergies or sensitivities?

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* 25. Please list any medical conditions you have been diagnosed with.

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* 26. Please list any surgeries/operations you have had.

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* 27. Please list any medications you take.

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* 28. Please list any supplements you take.

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* 29. In the last 12 months have you changed or discontinued any medications?

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* 30. Have you ever been tested for celiac disease or gluten sensitivity?

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* 31. Have you ever been diagnosed with cancer of any type?

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* 32. Have you ever been diagnosed with a thyroid condition?

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* 33. Do you feel any of the following symptoms?

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* 34. How well do you sleep?

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* 35. What would you say your general level of stress is?

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* 36. Do you smoke?

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* 37. Do you drink alcohol?

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* 38. Do you use any recreational drugs?

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* 39. Do you follow any of the following diets?

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* 40. How would you classify your physical fitness?

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* 41. Has there been hair loss in your family?

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* 42. May we ask if your mother and/or father are still living?

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* 43. Is there a family history of any of the following?

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* 44. Do you have a drug plan (are your medications partially or fully covered)?

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