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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

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

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?

Do you have any of these allergies or sensitivities?

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?

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

WE BELIEVE NOTHING IS MORE PRECIOUS AND VALUABLE THAN YOUR HEALTH AND BEAUTY

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