Hair Loss/Restoration - pre-clinic questionnaire Survey

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

Diagnosis

PRP (Platelet Rich Plasma)

LLLT (Low-Level Laser Therapy)

Hair Loss Supplements

Hair Transplant Surgery

I don't know what any of these are...

Other (please specify)

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

within the last week or two

1-3 months ago

3-6 months ago

6 months - 1 yr ago

1 yr-5 yrs ago

more than 5 years ago

specific date of event

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

Yes

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* 5. Have you ever had a scalp biopsy?

Yes

Unsure

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

My temples have less hair

My front hairline has less hair

The front half of my head is thinner

The sides of my head (above the ears) has less hair

The very top of my head is thinner

The back of my scalp is thinner

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

Specific area/spot

all over

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

Over the counter - Topical medicines (lotions, shampoos, mousse)

Over the counter - Oral medications (over the counter, supplements)

Prescription - Topical medicines (lotions, shampoos, mousse)

Prescription - Oral medications (prescription)

Other

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

Yes

Unsure

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* 10. Do you use any of the following?

Wig

Hair piece

Extensions

Camouflage fibers or powder

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* 11. Do you dye your hair?

Yes

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* 12. Do you have any grey hair?

a bit

a lot

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* 13. Do you get itchy scalp?

Yes

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

Above average

Average

Below average

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

Burning

Tingling

Both

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

Yes

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* 17. Do you get dandruff?

Yes

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* 18. Is your hair shedding more than usual?

A great deal

A lot

A moderate amount

A little

None at all

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

Yes

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* 20. How often do you shampoo your hair?

never

Every day

6 times per week

5 times per week

4 times per week

3 times per week

2 times per week

once per week

less than once per week

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

Yes

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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?

None

Face

Ears

Behind ears

Eyelids

Neck

Back

Chest

Hands

Other

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* 24. DO you have any allergies or sensitivities?

Allergies:

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?

Yes

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

Yes

If yes, please specify type and treatment/

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

Yes

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

Fatigue, more tired than you should be

Feeling cold when others around you don't

Abnormal menstrual cycle

Unexplained weight gain

Brittle, cracking, or splitting nails

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* 34. How well do you sleep?

High quality

Neither high nor low quality

Low quality

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

Very high

Above average

Average

Below average

Very low

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* 36. Do you smoke?

Yes

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* 37. Do you drink alcohol?

Yes

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* 38. Do you use any recreational drugs?

Yes

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

I do not follow a specific diet

Low fat

Low Carb

Keto

Gluten-free

Dairy-free

Vegetaria

Vegan

High Protein

Low Calorie (calorie deficit)

Low sodium

Diabetic

Other (please specify)

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* 40. How would you classify your physical fitness?

Far above average

Above average

Average

Below average

Far below average

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

There are some balding/thinning people on my FATHER'S SIDE ONLY

There are some balding/thinning people on my MOTHER'S SIDE ONLY

There are some balding/thinning people on my MOTHER'S side of the family AND my FATHER'S SIDE OF THE FAMILY.

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

Rather not comment

Only Father still living

Only Mother still living

Both Mother and Father still living

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

Rheumatoid Arthritis

Alopecia Areata

Breast Cancer in mother

Breast Cancer in sister

Multiple Sclerosis

Diabetes

Inflammatory Bowel Disease (Crohn's Disease or Ulcerative Colitis)

Vitiligo (loss of pigmentation of the skin - light patches)

Thyroid Problems

Lupus (also known as Systemic Lupus Erythematosus)

None

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

No drug plan

Partial Coverage

Full Coverage

Hair Loss/Restoration - pre-clinic questionnaire

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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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