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TrichoTest
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
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