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Survey for Black Women with Alopecia
This research is sponsored by black female researchers who are interested in your journey with alopecia. More and more black women, young and old are suffering from alopecia and losing their hair. This survey will provide us with information and insight into the experience, feelings, health conditions, struggles, commonalities and ideas. The goal is to gather information and work towards reversing this trend. We understand that alopecia is an autoimmune disease that many black women are suffering from. The question is - Why? Thank you in advance for your participation. The survey is less than 3 minutes.
Overall, how does having alopecia make you feel?
Sad/Depressed
1
2
3
4
5
Does not Bother Me
How long have you had alopecia?
*
Please select
1-5 years
6-10 years
11-15 years
16+ years
Do you feel that having alopecia has impacted your self-esteem.
Please select
Yes
No
Please tell us why you feel that way.
Demographic Questions
Age
*
Please select
Under 20
21-30
31-40
41-50
51 +
Work Status
Please select
Employed
Unemployed
Retired
Education Level
Please select
High School
Bachelors
Masters
Doctorate
Other
Geographic Location
Please select
North
South
East
West
Outside of U.S.
Work Classification
Please select
Blue Collar
Professional
Student
Income Level Range
Please select
Under $25,000
$25,000-$50,000
$51,000-$75,000
$75,001-$100,000
$100,0001+
Your Hair Care Journey
Do you allow your scalp to breath daily? No head coverings, including wigs.
Please select
Yes
No
Have you been treated by a physician for your alopecia?
Please select
Yes
No
Have you been prescribed a medication to cure your alopecia?
Please select
Yes
No
Do you currently wear your hair natural?
Please select
Yes
No
Do you wear wigs?
Please select
Yes
No
In the past
Do you relax (perm) you hair?
Please select
Yes
No
In the past
Do you color your hair?
Please select
Yes
No
Do you wear extensions?
Please select
Yes
No
In the past
Do you wear weaves?
Please select
Yes
No
Do you use a homemade recipe to cure your alopecia?
Please select
Yes
No
Is the medication or your recipe working?
Please select
Yes
No
What were you told by your doctor? What have you been prescribed to cure your alopecia, or what is your homemade recipe? or N/A
200 words max
Health
Do you have any health issues?
Please select
Yes
No
Are you over weight?
Please select
Yes
No
Have you ever been diagnosed with cancer?
Please select
Yes
No
Have you ever been diagnosed with endometriosis?
Please select
Yes
No
Have you ever been diagnosed with fibroids?
Please select
Yes
No
Do you have high blood pressure?
Please select
Yes
No
Do you take any medication?
Please select
Yes
No
Are you on medication for your mental health?
Please select
Yes
No
Have you been diagnosed with a mental health disorder?
Please select
Yes
No
Do you get migraine headaches?
Please select
Yes
No
Have you ever been diagnosed with infertility
Please select
Yes
No
Have you ever had titanium implants (teeth/body)?
Please select
Yes
No
Are you Vitamin D deficient?
Please select
Yes
No
Have you ever used a skin lightener?
Please select
Yes
No
Do you drink 64 ounces (8 -8oz. cups) of water daily?
Please select
Yes
No
Lifestyle
At any point in your life did you experience trauma (distressing or disturbing experience)?
Please select
Yes
No
Do you lead a stressful life?
Please select
Yes
No
Is the stress caused by home life?
Please select
Yes
No
Is the stress caused by work?
Please select
Yes
No
Are you married or live with a partner?
Please select
Yes
No
Would you classify your relationship as healthy?
Please select
Yes
No
Does your extended family cause you stress?
Please select
Yes
No
Are you a caretaker for a family member?
Please select
Yes
No
In the past
Do you face age discrimination at work?
Please select
Yes
No
Do you face racial discrimination and microaggressions at work?
Please select
Yes
No
Do you face religious discrimination at work?
Please select
Yes
No
Do you face sexism at work?
Please select
Yes
No
Do you exercise?
Please select
Yes
No
Do you take time off to relax?
Please select
Yes
No
Do you meditate?
Please select
Yes
No
Do you drink soda?
Please select
Yes
No
Do you drink alcohol?
Please select
Yes
No
Do you smoke cigarettes?
Please select
Yes
No
Financial Stress
Are you financially in a good place?
Please select
Yes
No
Does your financial situation cause you stress?
Please select
Yes
No
What goals have you set or plans do you have to change your financial situation and reduce your stress? or N/A
200 words max
Please share any thoughts, concerns, ideas that you think would be helpful to this research initiative or N/A. Thank you
200 words max
Provide your email address if you would like to be notified of the survey results and our progress on improving the health of black women. Please share this survey with your family and friends.
Email address
