Hair Restoration Form

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Have you experienced hair loss before?

Yes

No

If yes, when did you first notice it?

Do you have a family history of hair loss?

Yes

No

If yes, please specify the relationship (e.g., mother, father, sibling)

Have you been diagnosed with any of the following conditions? (Check all that apply)

Thyroid disorders (e.g., hypothyroidism, hyperthyroidism)

Autoimmune diseases (e.g., lupus, alopecia areata)

] Hormonal imbalances (e.g., polycystic ovary syndrome)

Scalp conditions (e.g., psoriasis, seborrheic dermatitis)

Other

If other, please specify

Do you have frequent or unexplained headaches?

Yes

No

If yes, please specify

Have you recently undergone any medical treatments or surgeries?

Yes

No

If yes, please specify

What type of hair loss are you experiencing? (Check all that apply)

If other, please specify

How would you describe the pattern of your hair loss?

Gradual

Sudden

Fluctuating

Other

If other, please specify

Have you noticed any changes in your hair texture or quality?

Yes

No

Do you have any dietary restrictions or follow a specific diet?

Yes

No

How would you rate your stress levels in the past 6 months?

Low

Moderate

High

Do you use any hair products regularly? (Check all that apply)

If other, please specify

Have you tried any treatments for hair loss?

Yes

No

If yes, please specify

Is there anything else you would like to share regarding your hair loss?

Please provide photos of the top of your scalp

Upload

Please provide photos of the side of your scalp

Upload File

Please provide photos of the other side of your scalp

Upload File

What is your full name?

What is your phone number?

What is your Alberta Health ID?

What is your email?

Hair Restoration Form

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