Hair Questionnaire Please complete the questionnaire below Hair Grading Scale TrichoTest First name Last name Email address Birthday Mobile Number Full home address with post code This information is required to post your DNA kit PATIENT'S DATA Height (cm) Weight (kg) FAMILY AND DISEASE DATA Type of alopecia Androgenic alopecia Telogen Effluvium (seasonal) Alopecia areata Androgenic Alopecia It is common type of hair loss that affects both men and women. It is also known as male pattern baldness for men, described as the loss or thinning of hair on the head's crown or hairline shrinking from the temples. A U-shaped hair pattern around the back and sides of the head normally stays or hair may keep on falling out, leading to complete baldness as time passes. Alopecia Areata A condition generated when the immune system of the body targets the hair follicles and disturbs the natural hair growth and formation. It is still unknown what causes it, but it seems to be an anomaly wherein the immune system targets specific body tissues. Biopsies of the skin affected reveal immune cells within the follicles of hair, when they are not present normally. Alopecia areata is oftentimes linked to other autoimmune conditions like ulcerative colitis, rheumatoid arthritis, lupus, vitiligo, thyroid disease and allergic disorders. Alopecia areata in some cases happens in several members of the family, indicating a role of heredity and genes. Telogen Effluvium It is a loss of hair that occurs when the hair follicles are pushed prematurely in the growth's resting stage by illness or stress. Grade your condition by using the hair grading scale on the top of the page 1A 1B 1C 1D 2A 2B 3 Advance Frontal Direct family members suffering from alopecia and / or hair loss None Parents Siblings Both For how long has your hair been falling out? More than a year Less than a year My hair doesn't fall out Do you have hypersensitivity to caffeine? Yes No Hypersensitivity Minoxidil Latanoprost Prostaquinon 17-α Estradiol Cetirizine Finasteride Dutasteride Cyproterone Spironolactone Tretinoin Do you consume any of the following substances? Alcohol Tobacco Cannabis Cocaine LSD Benzodiazepines Barbiturates Amphetamines Do you take any of the following medications? Anti-acne Antidepressants Antihypertensive Contraceptives Corticoids Estrogen synthesis inhibitors SADBE Do you have any of the following diseases? Hypothyroidism Hyperthyroidism Diabetes Cushing Syndrome Polycystic ovarian syndrome (PCOS) Endometriosis Hypertension Hirsutism Anemia Autoimmune diseases Cáncer Benign prostatic hyperplasia SAHA (Seborrhoea, Acne, Hirsutism & Alopecia) Cardiovascular diseases Hypotension Oestrogenic hormonal imbalance Do you have any of these allergies or sensitivities? Pollen Mites Fungui Animal hair Insect bite NSAID Antibiotic Insulin Propylene glycol alcohol Penicillin Are you currently following a hypocaloric diet? Yes No Do you have any of these eating disorders? Bulimia Vigorexia Anorexia Do you take testosterone (anabolic) derivatives? Yes No Are you pregnant? Yes No DATA RELATED TO YOUR ENVIRONMENT Do you suffer stress? Yes No Do you have depression? Yes No Have you recently had a child? Yes No Do you have irregular menstruations? Yes No Is your work in contact with toxic / polluting materials? Yes No Have you recently made a change of residence? Yes No Do you rest enough? Yes No Do you have post-surgical stress? Yes No Does menstruation come to you abundantly? Yes No DATA FROM YOUR LATEST ANALYTICS Cholesterol level? High Normal or Unknown Low Level of hematocrit? High Normal or Unknown Low TSH level (thyroid)? High Normal or Unknown Low T4 level? High Normal or Unknown Low Level of hemoglobin? High Normal or Unknown Low Size of red blood cells? High Normal or Unknown Low T3 level? High Normal or Unknown Low Do you use any of these hair products? Hair spray Gummies Hair gel Hair dryer Hair dyes Baseball cap Hair straightener CLINICAL INSPECTION Hair length Long Short Last time you washed your hair Less than 24 hours ago More than 24 hours ago Do you have alopecic plaques? Psoriasis vulgaris (also known as chronic stationary psoriasis or plaque-like psoriasis) is the most common form and affects 85–90% of people with psoriasis.Plaque psoriasis typically appears as raised areas of inflamed skin covered with silvery-white, scaly skin. These areas are called plaques and are most commonly found on the elbows, knees, scalp, and back. Yes No Are you using any treatment or supplement for alopecia at the moment? Please indicate which And in the past? Indicate which Pull test Pull Test and Tug Test This simple test measures the severity of hair loss. During a pull test, a dermatologist grasps small sections of hair, about 40 strands, from different parts of the scalp and gently tugs. If six or more strands fall out, you have what’s known as active hair loss. Unknown Positive Negative How does your hair look? Very Bad Bad Normal or Unknown Good Very Good How much hair falls out? A lot Little bit Nothing Do you have any of the following conditions on the scalp? Seborrhea Scales Scabs Irritations Psoriasis Seborrheic dermatitis Dandruff Dermatitis Alopecia is noticeable on your: Eyebrows Beard Eyelashes