Hair Loss Questionnaire

advertisement
Angela Lamb, M.D.
Director, Westside Dermatology
Department of Dermatology
Appointments: 212-241-9728
Patient Care Line: 212-828-3280
Fax: 212-828-3297
[email protected]
Hair Loss Questionnaire Hair loss generally falls into one of the following categories. If you are experiencing: 1. Diffuse shedding, (defined as having excessive numbers of hairs falling out daily), please complete Part I. 2. Diffuse thinning, (defined as having less hair to cover your scalp, with or without excessive hairs lost each day), please complete Part I 3. Hair loss in patches, (defined as having round or irregular areas of total hair loss, scalp or other hair-­‐except male pattern baldness), please skip to Part II on page 3. Part I: DIFFUSE SHEDDING or DIFFUSE THINNING 1. Do you feel you have been shedding excessive numbers of hairs? (i.e. with grooming, brushing, in the shower or tub with shampooing, on your pillow?) ! Yes ! No 2. Do you feel that your scalp hair is slowly thinning out over the top without losing excessive numbers of hairs daily? ! Yes ! No 3. Of the above two events, which was the first thing you noticed? ! shedding ! thinning 4. Are your hairs: ! Breaking off ! Coming out with the root attached (white “club” root at end) 5. Approximately how long have you noticed thinning or shedding? _______years _______months 6. Is your hair loss: ! Diffuse (evenly all over your scalp) ! Most noticeable over the top of your scalp 7. Are you losing hair in areas other than your scalp? ! Yes, where:______________________________ ! No 8. In the next questions include grandparents, parents, siblings, children, aunts and uncles. • Is there a family history of males with male pattern baldness or thinning? ! Yes ! No • Is there a family history of females with thinning over the top of the scalp? ! Yes ! No 9. Please indicate what you eat on an average day. Please include breakfast, lunch, and dinner. (We are particularly interested in protein intake.) • Breakfast: ____________________________________________________________________________________________ • Lunch: ________________________________________________________________________________________________ • Dinner: _______________________________________________________________________________________________ • Snacks: ________________________________________________________________________________________________ 10. Past medical history: Please specify if you have had recent: (*Please include dates beginning with the most recent.) • Illness: ________________________________________________________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________ • Surgery: ______________________________________________________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________ • Fever: _________________________________________________________________________________________________ Angela Lamb, M.D.
Director, Westside Dermatology
Department of Dermatology
•
•
Appointments: 212-241-9728
Patient Care Line: 212-828-3280
Fax: 212-828-3297
[email protected]
_________________________________________________________________________________________________________ Childbirth: ____________________________________________________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________ Have been under unusual psychological stress: __________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________ 11. Do you permanent wave and/or color treat your hair? ! Yes; How often?____________________ ! No 12. Do you relax, hot comb or press your hair? ! Yes; How often?____________________ ! No For Women: 13. Are you currently using birth control pills, Depo-­‐Provera or Norplant? ! Yes (Brand:_____________________; Dose: _____________________; Start Date: _____/_____/_________) ! No 14. Have you stopped using birth control pills, Depo-­‐Provera or Norplant within the past year? ! Yes (Stop Date: ______/______/_________) ! No 15. Do you menstruate? ! Yes (duration and flow: ____________________________) ! No 16. Is your cycle regular? ! Yes ! No 17. What is your pregnancy history? • Total Number of Pregnancies: ______________________________________________________________________ • Number of abortions and/or miscarriages: _______________________________________________________ 18. Do you have excessive hairs on your: ! Chin ! Face ! Chest ! Around the nipples ! Legs ! Abdomen 19. Do you have: ! Acne ! Oily skin ! Dandruff 20. Are you post-­‐menopausal? ! Yes (What age?__________ ; ! Natural ! Surgical?) ! No 21. Are you on estrogen replacement? ! Yes (How long: _________________; Dose________________) ! No 22. Are you on progesterone replacement? ! Yes (How long: _________________; Dose_______________) ! No 23. Have you had a hysterectomy? ! Yes (Date: _____/______/__________) ! No 24. Were your ovaries removed? ! Yes ! No ** You may stop here unless you are experiencing hair loss in patches. ** Angela Lamb, M.D.
Director, Westside Dermatology
Department of Dermatology
Appointments: 212-241-9728
Patient Care Line: 212-828-3280
Fax: 212-828-3297
[email protected]
Part II. HAIR LOSS IN PATCHES They’re several types of hair loss occurring in round or extensive irregular patches, usually on the scalp. Answers to the following questions will assist us in learning more about your type of hair loss. 1. What is your ethnic or racial group: _______________________________________________________________________ 2. Age of onset: (When first patch was noticed) _____________________________________________________________ 3. Duration of hair loss: ________________________________________________________________________________________ 4. Duration of current episode: ________________________________________________________________________________ 5. Number of episodes of hair loss, assuming your hair regrew fully in between each episode._________________ 6. What methods of treatments have you had, and how did your hair loss respond?______________________________________________________________________________________________________ _________________________________________________________________________________________________________________ 7. What is the most extensive hair loss you have ever experienced?__________________________________________________________________________________________________ 8. Is hair being actively lost at present?_______________________________________________________________________ 9. What sites on your body are affected by hair loss? (Check all that apply): ! Scalp only ! Eyelashes ! Eyebrows ! Pubic area ! Axillary/armpits ! Extremities ! Beard [in men] 10. Are your fingernails normal? _______________________________________________________________________________ 11. Do you have unusual skin eruptions/rashes/lesions?____________________________________________________ 12. Do you have a history of: ! Asthma ! Eczema ! Seasonal allergies/hay fever 13. Does anyone in your family have a history of asthma, eczema, or hay fever?__________________________________________________________________________________________________________ 14. Do you have any autoimmune diseases? (Check all that apply): ! Pigment loss (veiling) ! Thyroid disease ! Lupus ! Rheumatoid arthritis ! Scleroderma (hardening of the skin) ! Type 1/insulin-­‐
dependent diabetes ! Other:_______________________________________________________________________________ 15. Does anyone in your family have any of the above diseases? ___________________________________________ ________________________________________________________________________________________________________________ 16. Do you have any idea what triggers the hair loss episodes such as stress, infection, etc? _________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________ 
Download
Related flashcards
Dermatology

13 Cards

Create flashcards