Hair Loss/Hair thinning/alopecia Patient History Form
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1 Hair Loss/Hair thinning/alopecia Patient History Form We take hair loss very seriously due to the large impact it has on a patients quality of life. We therefore devote an alopecia clinic appointment for patients with this problem where more time, attention and detail can be given for this condition. As part of this, you need to be prepared for your visit. Your visit will only be focused on this condition. Hair loss appointments will not include skin checks, acne evaluation, cosmetics, etc. Guidelines for a productive visit include: -Do not shampoo hair for 1-2 days before visit -Bring a picture of your hair when it was not thinning -Do not comb or brush your hair that morning -Do not wear nail polish -Do NOT bring a bag of hair. We will examine and may pluck hair during your visit -Have all recent lab work available either you have a copy for the visit or you signed a release form for us to receive from your doctor. If not done, anticipate lab testing. -Have prior biopsy(ies) reports available either you have a copy for the visit or you signed a release form for us to receive from your doctor. If not done, anticipate a possible biopsy. ONSET 1. How long ago did the hair loss start? 2. Did it happen rapidly overnight? YES OR NO 3. Who noticed the hair shedding/hair loss? 4. Was your hair gray all of a sudden in a particular area? YES OR NO 5. Which family members have had hair problems (CIRCLE ALL THAT APPLY) a. Mom/Dad b. Siblings c. Children d. Grandparents 6. Is this the first and only time you have experienced hair loss? YES OR NO a. Is it different from the other time you experienced hair loss? Please explain. 1
2 SYMPTOMS 7. Is the hair shedding (you can see the hair bulb) or is it breaking? 8. Does your hair have a dry texture? YES OR NO 9. Is your scalp? a. Flaking YES OR NO b. Itching YES OR NO c. Painful or tender YES OR NO d. Sensitive or irritated YES OR NO e. Greasy YES OR NO f. Red (assessed in the mirror or what other people say) YES OR NO 10. Does your scalp have a funny odor sometimes? YES OR NO 11. Do you dye your hair? YES OR NO 12. Do you have any divots/impressions/dots or ridges on your nails? YES OR NO 13. Where do you see hair? a. Home b. Shower c. Other: 14. How many hairs do you estimate you are losing at a time? a. 100 YES OR NO b. >100 YES OR NO c. I don t know, but the hair is in clumps YES OR NO 15. Where have you noticed hair loss (CIRCLE ALL THAT APPLY)? a. Top/front of scalp b. Sides of scalp c. Back of scalp d. Armpits e. Groin f. Eyebrows g. Legs h. Eyelashes 2
3 16. Draw on the diagram where the hair loss is the most? 17. Women, do you have hair growth on your? a. Chin/thick sideburns YES OR NO b. Chest/nipples YES OR NO c. Area below your belly button YES OR NO TREATMENTS 18. What resources have you used to learn about hair loss? a. Internet YES OR NO b. Friends YES OR NO c. Any questions or concerns you have based on your research 19. Have you seen another doctor for this problem? YES OR NO a. If yes, was lab testing performed? YES OR NO This must be brought to your visit or sent before your visit b. If yes, was a biopsy performed? YES OR NO This must be brought to your visit or sent before your visit 20. Are you using Rogaine/Minoxidil? YES OR NO a. Strength (2 or 5%) b. How often (once or twice a day) c. Are you consistent with use? YES OR NO d. How long have you used it? e. Did it work? YES OR NO f. Did it cause more hair to fall out in the beginning? YES OR NO g. Any side effects? 21. Are you using anything else to treat your hair loss? a. Biotin YES OR NO dose: 3
4 b. Spironolactone/aldactone (dose) YES OR NO dose: c. Shampoo/conditioner system like viviscal YES OR NO d. Finasteride/Propecia YES OR NO dose: e. Dutasteride YES OR NO f. LED light helmets YES OR NO g. Ketoconazole shampoo YES OR NO h. Prednisone YES OR NO dose: i. Antibiotics (doxycycline, clindamycin, benzoyl peroxide) YES OR NO list: j. Prior steroid injections YES OR NO k. Iron supplements (dose) YES OR NO dose: l. Other vitamins (list:) 22. Any side effects from treatments( i.e scalp irritation, dizziness, hair growth in unwanted areas, breast enlargement, etc) 23. Has any treatment helped more than others (explain)? 24. What goals or expectations do you have for treatment? SOCIAL IMPACT 25. What is your occupation? 26. How severely has it affected your life? 27. Are you fearful of becoming bald? 4
5 DERMATOLOGY LIFE QUALITY INDEX (adapted) this screening will be repeated at future visits Name: Date: Score: The aim of this questionnaire is to measure how much your hair loss has affected your life OVER THE LAST WEEK. Please tick one box for each question. 1. Over the last week, how itchy, sore, Very much painful or stinging has your scalp A lot been? A little Not at all 2. Over the last week, how embarrassed Very much or self conscious have you been because A lot of your hair loss? A little Not at all 3. Over the last week, how much has your Very much hair loss interfered with you going A lot shopping or looking after your home? A little 4. Over the last week, how much has your Very much hair loss influenced the clothes A lot you wear like hats? A little 5. Over the last week, how much has your Very much hair loss affected any social or A lot leisure activities? A little 6. Over the last week, how much has your Very much hair loss made it difficult for A lot you to do any sport? A little 7. Over the last week, has your hair loss prevented Yes you from working or studying? No 5
6 If "No", over the last week how much has A lot your hair loss been a problem at A little work or studying? 8. Over the last week, how much has your Very much hair loss created problems with your A lot partner or any of your close friends A little or relatives? 9. Over the last week, how much has your Very much hair loss caused any sexual A lot difficulties? A little 10. Over the last week, how much of a Very much problem has the treatment for your A lot hair loss been, for example by making A little your home messy, or by taking up time? Please check you have answered EVERY question. Thank you. AY Finlay, GK Khan, April this must not be copied without the permission of the authors. 6
7 Check the box(es) if you are experiencing any of the following: Problem with bleeding Excessive fatigue Dry eyes Unintentional weight loss or gain Staphylococcal infections Problems with scarring (hypertrophic or keloid) Artificial heart valve Artificial joints placed within the past two years Blood thinners (aspirin, warfarin) Defibrillator Allergy to lidocaine/anesthetics Allergy to topical antibiotic (Neosporin) Problems with healing Joint or back aches Change in vision or blurry vision Abdominal pain Migraines Irregular menses/periods Dry mouth Hair loss Rash with use of adhesive bandages Currently pregnant or planning a pregnancy Leg swelling Muscle Weakness Past Medical History (Please circle all that apply) Anxiety Asthma Hay Fever/Allergies Depression Diabetes Kidney Disease Liver disease HIV/AIDS Thyroid Problems Leukemia Lymphoma Radiation Treatment Sjogren s syndrome Lupus Past Surgical History: (please circle all that apply) Mechanical Heart Valve Replacement Biological Heart Valve Replacement Joint Replacement within last 2 years Bone Marrow Transplantation Organ Transplantation 7
8 Skin Disease History: (please circle all that apply) Acne Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Sun sensitivity Psoriasis Family History: Eczema: siblings /mother / father / child / grandparents Psoriasis: siblings /mother / father / child / grandparents Medications: Please all medications you take from other doctors and length of therapy 8
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