JENNIFER W. PENNOYER, M.D. Medical, Cosmetic & Laser Dermatology

Solutions

Hair Loss Questionnaire

A detailed intake questionnaire helps Dr. Pennoyer understand your history and identify the factors contributing to your hair loss. Fill it out below, then print or save it to bring to your visit.

Please complete as much of this questionnaire as you can before your visit. When finished, use the Print / Save as PDF button to print it or save a copy to bring with you. The more complete the picture, the more productive your consultation will be.

1. How long has it been since your hair seemed “normal”? Is your problem getting worse, better, or is it stable?

2. What has changed? Check each that applies.

3. Family history of hair loss? Mark Yes or No for each.

Mother
Maternal Aunts
Maternal Uncles
M. Grandmother
M. Grandfather
Sister(s)
Father
Paternal Aunts
Paternal Uncles
P. Grandmother
P. Grandfather
Brother(s)

4. Please list all medication you are currently taking and the condition being treated.

5. Please list any medications you have discontinued in the last year.

6. Do you have any allergies?

7. Hormonal History (women)

8. Do you have a history of any of the following?

9. Please list any physicians or other providers you have seen for your hair loss, along with approximate dates of visits.

10. What treatments have you tried for your hair loss, and what results did you have?

11. What are your hair care and styling practices? (Coloring? Perming? Treatments with heat or chemicals? Frequency of shampooing?)