1. Gender
FemaleMale

2. Choose the color below that most closely describes your natural hair color?
BlackRedBrownRed-BrownBlondeGraySalt and PepperOther: (Please Specify)

3. From the list below choose the texture that best describes your natural hair. Choose all that apply.
Tightly curledKinkyWavyLoose CurlStraightOther: (Please Specify)

4. Please mark how often you groom your hair in each of the following styles.
(1 = Never, 2 = Seldom, 3 = Occasional, 4 = Often, 5 = Most of the time, 6 = Always)
Natural
Braids
Pony Tail
Weave
Corn Rows
Straight
Waves
Sister Locks
Twists
Wig
Other: (Please Specify)

5. Regarding Straightening, how often have you done the following?
(1 = Never, 2 = Occasionally, 3 = Off and on over the years, 4 = Moderate Use; stopped more than 3 months ago, 5 = Heavy use; stopped more than 3 months ago, 6 = Currently using)
Chemical
Flat Iron
Keratin and Blow-Dryer

6. Please state how often you wash your hair.
(1 = 7 times a week, 2 = 3-4 times a week, 3 = 1-2 times a week, 4 = Every 2 weeks, 5 = Every 3 weeks, 6 = Every 4 or more weeks)
Water
Soap
Shampoo
Other: (Please Specify)

7. Please state how often you Condition your hair.
(1 = 7 times a week, 2 = 3-4 times a week, 3 = 1-2 times a week, 4 = Every 2 weeks, 5 = Every 3 weeks, 6 = Every 4 or more weeks)
Using Conditioner
Using Oils
Defrizzer/Detangler
Pomade
Other: (Please Specify)

8. Please indicate your use of the following nonprescription hair treatments.
(1 = Never used, 2 = Used more than a year ago, 3 = Used 6 months ago, 4 = Used 3 months ago, 5 = Currently using)
Minoxidil
Laser caps or laser combs
Other: (Please Specify)

9. If you have tried other hair treatments what has been your experience? (Specify Product Name)
Didn't work at all
Worked somewhat
Worked very well
Might have worked if I continued to use it
Had a reaction to the product
Liked it but dried out my scalp too bad
Made my scalp itch
Couldn't stand the smell
Product did not penetrate my hair
Worked in some areas but not others
Made the problem worse
Other: (Please Specify)

10. Referring to the pictures on the hair loss chart provided at the end of this questionnaire, please indicate the extent of hair loss.
Female:
1-211-2111AdvancedFrontalTraction Alopecia
Male:
IIIIIIIVVVIVII

11. If you have ever been treated by a doctor for hair loss what was the diagnosis?
Never treated by a doctor for hair lossAndrogenic Alopecia (genetics)Traction Alopecia (from pony tails, tight braids, etc)Central Centrifugal Cicatricial Alopecia (CCCA) (Chemical or hot comb induced)Lichen Plano Pilaris (LPP)Frotal Fibrosing Alopecia (FFA)Alopecia areataLupusDandruff/severe scalp dryness and flakingOther: (Please Specify)

12. Mark any of the following tests you've had for hair loss. Mark all that apply.
Hair pull testBlood workScalp BiopsyOther: (Please Specify)

13. If you've ever been treated by a doctor for hair loss, please provide the doctor's name and contact information below.

14. If you've ever been treated by a doctor for hair loss, please provide the type of treatment, duration of treatment.
MinoxidilFinasterideHydroxychloroquiine/PlaquanilDoxycycline/MinocyclinePlatelet Rich PlasmaMicroneedlingMesotheraphyScalp Steriod InjectionsOther: (Please Specify)
Please provide previous treatment information if selected above

15. Mark any of the following conditions that you have. Choose all that apply.
High blood pressureLow blood pressureDizzinessFainting spellsOther: (Please Specify)

16. Please list any prescription medications you are currently taking or have taken in the past.

17. Please list any over-the-counter medications you are currently taking or used in the past.

18. Please list any herb, vitamins, or natural supplements you are taking or used in the past.

19. Please indicate if you are allergic to any of the following. Check all that apply.
Any plant or plant extractAny flower or flower extractAny oilsOther: (Please Specify)

20. Please use the space below to explain anything else you think would be helpful for us to know about your hair condition hair grooming habits or medical condition that we did not think to ask.