Intake Hairloss – Northwestern Access

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Status

New

On hold

Complete

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Provider ID (Hidden)

This clinical history takes 5-7 minutes to complete, you can save in case you need to pause.

What is your gender?(Required)

Male

Female

What's your date of birth?(Required)

What type of hair loss have you been experiencing?(Required)

Progressive thinning

Excessvie shedding (100+ hair/day)

Both

Certain symptoms can indicate less common types of hair loss. Have you experienced any of the following?(Required)

Itching, burning, bumps, discoloration, or rashes on your scalp

Hair loss other than your head

Sudden increase in hair loss

Dandruff, scaling, or greasiness of your scalp

None of the above

The next few questions will help us understand what treatments have and have not worked for you in the past.

Please tell us how these treatments worked for you(Required)

Do you plan on continuing to use any of these treatments?(Required)

Yes

The following questions help us understand if there are any underlying medical causes of your hair concerns.

Are you being treated and how well is your treatment going?(Required)

Have you seen a medical professional about your hair loss?

Yes

Have you been diagnosed with any other medical conditions?

Yes

Have you had any surgeries?

Yes

Are you taking any medications?

Yes

Please list your allergies to medications.(Required)

If none, please type 'none.'

Are you pregnant or planning to be pregnant in the next 6 months?(Required)

Yes