Hair Loss & Health Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *I am *a mana womanEven when clean, my head itches *Yes, almost all the timeNoFrom time to timeI do not know / I do not remember / Nothing in particularIn which area of the head are you losing/did you lose your hair? (Select all that apply) *On temples / in frontOn topClose to earsAt the nape of the neck What Here etc.). Do/did you lose your hair in patches? *YesNoNot really / Do not knowI am losing / I lost my hair in big chunks: *Yes, reallyYes, a bitNoNot sure / Do not remember / OtherAt the same time, I am losing / I have also lost all my eyebrows / eyelashes: *YesNoA little bitI usually have dandruff / scabs on my head: *Yes, definitelyYes, sometimesNoNot really / Not a lot / Do not knowI am losing / I have lost the hair of my beard / mustache: *Yes, most of themNoYes, a littleDoes not apply / Do not remember / Do not knowI am losing / I have lost the hair of my beard / mustache: (copy) *Yes, most of themNoYes, a littleDoes not apply / Do not remember / Do not knowIs there anything special about your hair? (Example: texture, color, smell, completely matted, strange regrowth, pubic hair, etc., or nothing special) (copy)Hair loss sometimes occurs at specific times (e.g., changing job, stress, illness, childbirth, etc.). What events are linked to your hair loss?Tell me the story of your hair loss:Did you ever have any of the following conditions? *GonorrheaTuberculosisSyphilisDo not know / Do not answer / Do not rememberDo you have skin-related issues? (Check all that apply) *EczemaPsoriasisAcneWartsRosaceaUrticariaCold soreAphthous ulcer (canker sore)StyeSkin tagsPusThe health of your hair depends on blood circulation, your immune system, etc. Here are several questions: Is there a part(s) of your body that is very hot all the time? (Check all that apply) *HandFootNoseOther zoneDo not know / HesitateIs there a part(s) of your body that is very cold all the time? (Check all that apply) *HandFoot and/or legFace and/or noseAnother locationNowhere in particularDo not know / HesitateGenerally speaking, I really can’t stand: (Check all that apply) *HeatColdness / CoolnessNothing special / A bit of both / I manage / I do not like / I do not knowGenerally speaking, I feel really great when: (Check all that apply) *It dependsWith warm drinksIn the sunWith air conditioningIn the shadeNothing special / A bit of everything / I do not know / I hesitateNails and Personality: Hair and nails are close relatives. My natural nails are: *Very softBreak easilyDo not know / Not sureDo you have a health problem or illness identified by the medical system?Submit
