Hair Loss Clinic
Please answer the following questions prior to your visit.
Name:
Address:
Phone number:
Sex: male
female
Race: White
Black
Asian/Pacific
Date of Birth:
Age:
Hispanic
American Indian/Alaskan Native
Other___________________
MAIN COMPLAINT: Please check all that apply to you.
I am most concerned about my…
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Hair: (please circle one)
I am losing it.
It is growing excessively.
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Skin: (describe)
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Nails: (describe)
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Teeth: (describe)
HISTORY OF MAIN COMPLAINT:
Please answer these questions regarding the problem that is most concerning to you.
How long have you been experiencing symptoms?
Characterization of main complaint:
 At what age did you first begin to notice these symptoms:______________
 How many episodes have you experienced since that time:___________
 How frequently do these episodes occur:____________
 How long do these episodes last:_____________
 Do your symptoms begin suddenly or gradually?___________
 Are your symptoms continuous (present all the time) or intermittent (come and
go)?______________
 Are you able to camouflage your condition: yes
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no
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 How severely does this problem impact your activities of daily living: (please circle
one) not at all
minimally
moderately
severely
debilitating
 What areas are affected by this problem: (circle all that apply)
scalp
eyebrows
eyelashes
beard
mustache
chest/breasts
back
abdomen
arms
legs
underarms
genital area
other__________________
 Please list any factors that aggravate or alleviate this
problem:_________________________________
 Are there any other symptoms associated with this problem:_________________
 Does anyone in your family have a similar condition:_______________________
Social:
 Please describe your diet:_______________________________________
 How often do you exercise:______________________________________
 Do you smoke?_____ If yes, how many cigarettes/day.
 Do you drink alcohol?______If yes, how many drinks/week.
 Who lives at home with you?_________________________________
 Please list the stressors in your life:_______________________________
Hair Loss Clinic
Please answer the following questions prior to your visit.
Current Medications: Please list all medications that you are currently taking. Include
all over-the-counter medications as well as vitamins and herbal medications.
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
Please list your allergies:
Previous evaluation:
 Have you been evaluated for this problems in the past?_________________
 Were you given a diagnosis?______________________________________
 Did your evaluation include any laboratory tests or skin biopsies?____________
If yes, when were those tests done?_____________________________________
Previous treatments:
 Have you been treated for this problem in the past?____________
 Please list any treatments that you have tried for this problem:
______________
Response:_______________________________________
______________
Response:_______________________________________
______________
Response:_______________________________________
______________
Response:_______________________________________
______________
Response:_______________________________________
WHAT DO YOU THINK CAUSED THIS PROBLEM?
WHAT IS YOUR MAIN CONCERN REGARDING THIS PROBLEM?
Hair Loss Clinic
Please answer the following questions prior to your visit.
PAST MEDICAL HISTORY:Please check all that apply to your medical history.
Allergies/asthma
Arthritis/joint problem
Dermatitis/eczema
Blood disease
Immune disorder
Skin condition
(anemia/bleeding)
Ear problem
Autoimmune disorder
Psoriasis
Eye problem
Rheumatoid arthritis
Acne
Respiratory/chest disease
Lupus
Blistering skin disease
Heart condition
Muscle problem
Vitiligo
Bowel/digestive problem
Nerve problem
Psychiatric disorder
Liver problem/gall bladder
Vein/vascular problem
Reproductive system
problem/hepatitis
problems
Diabetes
Kidney or urinary problem
Infertility problems
Thyroid disease
Cyst/polyp/tumor
Parathyroid disease
Cancer
Other medical problems: …………………………………………………………………..
FAMILY HISTORY:Please check all that apply to your family’s medical history.
Allergies/asthma
Arthritis/joint problem
Dermatitis/eczema
Blood disease
Immune disorder
Skin condition
(anemia/bleeding)
Ear problem
Autoimmune disorder
Psoriasis
Eye problem
Rheumatoid arthritis
Acne
Respiratory/chest disease
Lupus
Blistering skin disease
Heart condition
Muscle problem
Vitiligo
Bowel/digestive problem
Nerve problem
Psychiatric disorder
Liver problem/gall bladder
Vein/vascular problem
Reproductive system
problem/hepatitis
problems
Diabetes
Kidney or urinary problem
Infertility problems
Thyroid disease
Cyst/polyp/tumor
Parathyroid disease
Cancer
Other medical problems: …………………………………………………………………..
Hair Loss Clinic
Please answer the following questions prior to your visit.
Review of systems: Please circle all symptoms that you have had in the last week.
 General: weight change, fatigue, fever, chills, night sweats
 Head/ears/eyes/nose/throat: headache, visual changes, blurriness, tearing, itching
eyes, runny nose, congestion, nose bleed, hearing loss, ringing in ears, dizziness,
earache, bleeding gums, hoarseness, sore throat, swollen neck, swollen lymph
nodes (“glands”)
 Lungs: shortness of breath, wheezing, coughing, coughing up blood, coughing up
mucus, pneumonia, asthma, bronchitis, emphysema, TB
 Heart: high blood pressure, heart murmur, chest pain, heart “skipping-abeat”/racing
 Stomach/bowels: change in appetite, nausea, vomiting, diarrhea, constipation,
bleeding, abdominal pain, jaundice, hepatitis
 Kidneys/bladder: change in urinary frequency, burning/pain with urination,,
difficulty with urinating, blood in urine, accidents/losing urine
 Vascular/veins: leg swelling, pain in legs, varicose veins, history of clots
 Musculoskeletal: muscle weakness, pain, joint stiffness, joint instability, redness,
swelling, arthritis, gout
 Psychiatric: mood change, anxiety, depression, tension, memory change
 Neurologic: decreased sensation, numbness, tingling, tremors, weakness,
paralysis, fainting, blackouts, seizures
 Hematologic: anemia, easy bruising, easy bleeding, transfusions
 Endocrine: heat/cold intolerance, excessive sweating, thyroid problems, diabetes