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Hair Loss Questionaire
Hair Loss
Questionnaire
How would you describe your current degree of hair loss?
Early Stages
Moderate
Severe
When did you first notice you were losing hair?
Teen years
20-25 years old
26-30 years old
31-45 years old
46-50 years old
51+ years old
Which of the following are you currently experiancing?
Hair Shedding
Thinning
Breakage
Oily scalp
Itchy/dry/flaky scalp
Other
What part of your scalp is the most concerning to you
Hair line/ Temples
Frontal
Crown (top)
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