Section 1: Tell us about yourself
Full Name*
Email Address*
Age
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Even when clean, my head itches
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In which area of the head, are you losing/did you lose your hair
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Do/did you lose your hair in patches?
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I am losing/ I lost my hair in big chunks
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At the same time, I am losing/ I have also lost all my eyebrows/ eyelashes
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I am losing / I have lost the hair of my beard/mustache
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I usually have dandruff/scabs on my head
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Is there anything special about your hair (example: texture, color, smell, completely matted, strange regrowth, about pubic hair, etc, or nothing special)?
Hair loss sometimes occurs at specific times (changing job, stress, bereavement, illness, childbirth, accident, with medication, retirement, conflictual relationship, abortion, etc.). What events are linked to your hair loss?
Tell us the story of your hair loss
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Do you have skin-related issues?
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Section 2: The health of your hair depends on your 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)
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Is there a part(s) of your body that is very Cold all the time? (check all that apply)
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Are there any other areas of your body that are regularly painful?
Generally speaking, I really CAN NOT stand (check all that apply)
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Generally speaking, I feel really great (check all that apply)
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There is something special about me (check all that apply)
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Anything you would have a hard time living without (example : a sport, food, etc. or nothing special): If you don't know, write Nothing special.
One thing you absolutely hate/loath/scare the hell out of you (or nothing special):
You are unique! Are there any sensations/reactions that characterize you? (be specific, for instance : cold in a place, one area itches, feeling of having a grain of sand in the eyes, of having a helmet on the head, that a place burns, etc.). The more specific you are, the more you help us
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Think about your body, is there anything special? (be specific even if it has nothing to do with your hair at first glance, for example: health problem, dizziness, burning hands, flatulence, gurgling, sciatica, headache, obese, anemia, mucus, constipation-diarrhea, incontinence, etc.)
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Section 3: Hair and nails are close relatives.
Is there anything special about your nails (color, shape, feel, etc. or nothing special)?
You are: (Check all that apply)
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Can you describe yourself in about 10 words, with your strengths and weaknesses
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In general, the company of other people:
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Me and my surroundings:
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Generally speaking, in a group I like to:
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By nature I am (check all that apply):
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By nature I am (check all that apply):
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Do you have a health problem or illness identified by the medical system? (in general, even if it does not seem to be related to hairloss)
If there is anything else you think would be helpful and that was not asked, please let us know:
You are or were experiencing thyroid issues (level of TSH, T3, T4 out of balance)
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You were undergoing intensive medical treatment in the last few years (such as chemotherapy, radiotherapy)
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Your diet is unbalanced and you may have deficiencies (e.g., iron, protein, zinc, vitamins)
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You eat enough proteins in a day (0.8 g to 1 g/ kg of weight / day; i.e. 80 g of proteins for a person of 80 kgs)
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You are taking steroids or you were taking steroids
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You have lost weight very rapidly in the last years (extreme dieting or bariatric surgery,etc)
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You are not getting enough sleep
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End. Thank you. If you want to provide comments to improve this questionnaire you are welcome. We will come back to you within 2-3 weeks with the best match.
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