Dose the patient being treated have any of the following conditions?

• Pregnancy or nursing.

• Under 18 years old.

• No other family members have had hair loss (no family history of hair loss).

• Loss of the eyebrows or eyelashes.

• Women who have hair loss after giving birth.

• Changes in the fingernails or toenails along with hair loss.

• Receiving chemotherapy or other medications that can cause hair loss.

• Hair loss that could be from lack of nutrition (increasing protein and iron intake can help to treat hair loss from nutritional deficiencies).

• Hair loss from a burn or skin damage to the scalp.

• Sudden onset of severe hair loss.

• Patchy hair loss.

• Fever or other symptoms before hair loss begins.

• Recently stopped taking oral contraceptives.

• Sudden onset of acne, hair loss, menstrual cycle changes, or more hair growth on other body parts.

• Hair loss due to psoriasis or seborrheic dermatitis.


Yes

No



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