Hair Loss Evaluation Form
What a hair loss evaluation form asks, with sample questions on onset, family history, medicines, and hair care.
A hair loss evaluation form records when hair loss began, family history, recent health events, medicines, hair care, and scalp symptoms before a visit. It's also called a hair loss new patient information sheet.
Hair loss evaluation form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a hair loss evaluation form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample hair loss evaluation form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- When did you first notice hair loss?Onset
- Is your hair loss getting worse?Onset
- Does anyone in your family have hair loss?Family history
- Does anyone in your family have autoimmune disease?Family history
- Were you pregnant before or during the hair loss?Health events
- Were you seriously ill before the hair loss?Health events
- Which medicines were you taking when it started?Medicines
- Which vitamins or supplements do you take?Medicines
- How often do you shampoo your hair?Hair care
- How often is your hair dyed or highlighted?Hair care
- Do you have itching or tenderness on your scalp?Scalp
- Have you ever had a scalp biopsy?Scalp
These are examples to read, not a form to fill in.
Hair loss evaluation form: FAQ
What does a hair loss evaluation form ask?
The sample questions on this page are based on two medical practices' hair loss questionnaires, one from Virginia and one from Florida. This page groups them into six areas: onset, family history, health events, medicines, hair care, and scalp.
Who fills in a hair loss evaluation form, and when?
The patient, before the hair loss visit. Both forms ask what was happening before or during the hair loss, such as illness, stress, pregnancy, or diet changes.
Does it ask about medicines?
Yes. Both forms ask for current medicines, which ones were taken when the hair began to fall out, any stopped since, and vitamins or supplements.
Does it ask about hair care and styling?
Yes. Both forms ask how often the hair is washed, chemically processed, heat styled, or colored, and about past braiding, weaves, or tight hairstyles.
Is there a hair loss evaluation form template?
The sample questions on this page show a typical set. A form-builder template lists similar topics, including hair loss pattern, hormonal factors, stress, and lifestyle.
What happens after the form is completed?
The practice's team reviews the answers before the visit. AI Doctor only collects them; it does not suggest a cause or a treatment.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
