Hair Screening

Have you ever had an adverse or allergic reaction to hair growth medication/treatments in the past or to any of its ingredients?(Required)

Yes (Finasteride, Minoxidil, Azelaic acid, Latanoprost, Tretinoin, Ketoconazole, Biotin, Spironolactone, Melatonin, or some of its ingredients)

What products have you tried previously, including over the counter products?(Required)

Has your hair loss or thinning ever been related to a topical fungal infection?(Required)

Yes

Are you on any hormones- birth control, testosterone, estrogen, progesterone?(Required)

Yes

Are you pregnant or breastfeeding?(Required)

Yes

Do you have a personal medical history involving any of the following medical conditions?(Required)

Skin-prescribed products can have sun sensitivity and side effects on skin, including but not limited to drying, itching, redness, irritation

Eye- Irritation can occur from topical products

Prostate- cancer or any medical issues?- if yes, proceed to consult and do not proceed with finasteride

Heart attack- do not use minoxidil within 30 days of Myocardial infarction.

Adrenal tumor- pheochromocytoma- If yes, proceed to consult and do not proceed with minoxidil.

Thyroid disease

Anemia or Iron deficiency

None of the above

Please explain your answer to the last question.(Required)

Do you have a family history of Alopecia or hair thinning?(Required)

Yes

Please explain your answer to the last question.(Required)

Are you taking Spironolactone or Ketoconazole?(Required)

Yes

Are you taking any of the following medications?(Required)

When did you last have a normal head of hair?(Required)

Was onset of hair loss sudden or gradual?(Required)

Sudden

Gradual

Is your hair coming out “by the roots” or is it breaking off?(Required)

Roots

Breaking off

How many hairs would you estimate you shed per day?(Required)

< 50

50-100

100-150

150-200

Do you feel that your scalp hair is slowly thinning out over the top without losing excessive numbers of hairs daily?(Required)

Yes

How often do you wash your hair?(Required)

How often do you blow dry your hair?(Required)

Do you use hot rollers, ponytails, braids, twists, locks, extensions, or weaves?(Required)

Yes

Do you use hot combs, press and curl, curling irons, flat iron or otherwise apply direct heat to your hair?(Required)

Yes

What type of hair chemicals do you use for your hair?(Required)

Does your scalp itch?(Required)

None

Mild

Moderate

Severe

Does your scalp burn?(Required)

None

Mild

Moderate

Severe

Does your scalp hurt?(Required)

None

Mild

Moderate

Severe

Do you get sores in your scalp?(Required)

Yes

Do you pull or plug your hair?(Required)

Yes

Do you have seborrheic dermatitis (dandruff)?(Required)

Yes

Do you have Psoriasis?(Required)

Yes

Do you use herbs or supplements?(Required)

Yes

Which Ones?(Required)

Are you are on birth control pills or hormone replacement?(Required)

Yes

Which Ones?(Required)

Are you peri menopausal or menopausal?(Required)

Yes

Are you on any type of diet?(Required)

Yes

Which Kind?(Required)

Low Protein

Vegan

Vegetarian

Other

Have you ever had a biopsy of your scalp?(Required)

Yes

Have you had in the last 3-12 months any of these?(Required)

Hair Screening

Treatments

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