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Hair loss questionnaire
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We are looking for honest feedback from men and women that are currently or have sufferred from hair loss at some point in their lives. Steve McKeown is a trained psychotherapist who is currently researching the impact and effect(s) that hair loss (alopecia) has on a person psychologically in correlation to mental health.
The contents of this questionnaire will serve as a basis of his new book that he will be releasing to help hair loss sufferers better cope with this difficult change. All completed questionnaires are confidential and anonymous, although there is an optional field at the end whereby you can provide further details.
Please note key: HL - Hair Loss
You will note that some of the questions that are asked, ask you to elaborate if you have answered 'yes'. If you decide that you do not want to want to elaborate please leave the field blank but keep the 'yes' field checked. Please remember that the more you elaborate, the better the research will be.
Thank you in advance of completing this questionnaire.
Sex:
Male
Female
Age range:
18-23 yrs
24-29 yrs
30-35 yrs
36-41 yrs
42-47 yrs
48-53 yrs
54-59 yrs
60 yrs +
Ethnicity
White
Carribean
African
Indian
Pakistani
Bangladeshi
Chinese
Other
Was your HL gradual or sudden?
Gradual
Sudden
Are you continuing to lose your hair?
Yes
No
Does HL run in your family?
Yes
No
Unsure
Were you ever in denial about losing your hair? (Example: did you blame other things such as diet, alcohol, smoking etc. and not accept that you had androgenic alopecia - male pattern baldness).
Yes
No
If yes, please elaborate
Did you believe that your hair loss was due to something else, other then male/female pattern baldness?
Yes
No
If yes, please elaborate
Have you ever styled your hair around your balding areas? (Example: manipulate the hair you had around the areas of loss).
Yes
No
If yes, please elaborate
What was your biggest fear about losing your hair? Please state.
On a scale of 1 to 10 how upset was you when you first started losing your hair?
Did you ever feel angry with yourself about your HL?
Yes
No
If yes, please elaborate
Did you blame anyone else for your HL? (Example: Father, Mother etc.) Please state.
Yes
No
If yes, please elaborate
Were you ever angry towards others dues to your HL? (Example: ask your partner if your hair looked okay, only for them not to give you the correct answer, making you feel frustrated).
Yes
No
If yes, please elaborate
Have you ever felt socially anxious due to your hair loss?
Yes
No
If yes, please elaborate
Have you ever avoided a social situation due to your HL?
Yes
No
If yes, please elaborate
Do you feel that your HL has made it harder to make friends?
Yes
No
If yes, please elaborate
Do you feel that your HL has inhibited your ability to attract the opposite sex?
Yes
No
If yes, please elaborate
How do you think society views hair loss? Please state.
How do you think the opposite sex views your hair loss? Please state.
How do you think your friends and work colleagues view hair loss? Please state.
Has your HL negatively affected your overall image?
Yes
No
If yes, please elaborate
Have you ever been teased about your HL?
Yes
No
If yes, please elaborate
Do you feel HL has held you back professionally?
Yes
No
If yes, please elaborate
Has your HL negatively affected your sex life?
Yes
No
If yes, please elaborate
Do you believe your HL has affected your desirability?
Yes
No
If yes, please elaborate
Did you ever become desperate enough to use un-proven methods or techniques for HL?
Yes
No
If yes, please elaborate
Have you ever used topical treatments for your HL?
Yes
No
If yes, please elaborate
Have you ever felt the need to disguise your HL? (camouflage ).
Yes
No
If yes, please elaborate
Have you ever used a hair piece or other extension(s)?
Yes
No
If yes, please elaborate
Have you ever taken drastic extremes to prevent your HL?
Yes
No
If yes, please elaborate
When you first started to lose your hair, did you think your hair loss could be treated or cured?
Yes
No
If yes, please elaborate
Did you feel lost about where to go or which kind of treatment to select?
Yes
No
If yes, please elaborate
Where did you go for information and support? Please state.
What support services do you think would be helpful for someone in the same position? Please state.
What would regaining your hair mean to you? Please state.
Have you ever felt a general anxiety due to your HL?
Yes
No
If yes, please elaborate
Have you suffered depression due to your HL?
Yes
No
If yes, please elaborate
Have you ever taken anti-depressants?
Yes
No
If yes, please elaborate
Do you feel that your HL has reduced your confidence and esteem?
Yes
No
If yes, please elaborate
Do you think that your confidence would increase with a full head of hair?
Yes
No
If yes, please elaborate
Have you ever had suicidal thoughts pertained to your HL?
Yes
No
If yes, please elaborate
Do you feel that you HL is the main reason for your anxiety?
Yes
No
If yes, please elaborate
Do you feel that any anxiety you have/had with regards to your HL is disregarded by society?
Yes
No
If yes, please elaborate
Have you ever consulted your GP about your HL?
Yes
No
If yes, please elaborate
Do you feel that HL when in relation to mental health, should be taken more seriously be GP's?
Yes
No
If yes, please elaborate
Do you feel that there should be more advice from GP's about options that are available when losing your hair?
Yes
No
If yes, please elaborate
Further info (optional): At some point I will need to further my research so I would be grateful if you could provide me with your contact details including your name, telephone number and email address so that i may ask you some extra questions, please also remember that all details provided are confidential and will not be used for any other purpose.
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