1. Which grade describes best your condition?
2. Hereditary factors
If yes, is it from your father’s family?
If yes, is it from your mother’s family?
3. How many years ago did hair loss occur for the first time?
4. How old were you when you started losing your hair?
5. Do you still have hair loss?
If yes, do you see hair in the washbasin and/or on your pillow?
6. Have you ever received treatment for hair loss?
7. Is your scalp oily?
8. Do you suffer from seborrheic dermatitis on your scalp?
9. Do you have a history of iron (Fe) deficiency?
10. Do you suffer from any thyroid gland disorders?
11. Is your diet poor?
12. Have you lost weight quickly?
13. Did you have high fever lately?
14. How often do you wash your hair?
15. Have you been informed about the following hair loss treatment?
16. Do you receive any of the following medicines?
According to medical confidentiality, we are committed to maintaining the privacy of
medical and personal information entrusted to us and these data will not be published or
otherwise used apart from the purposes of this assessment.