1. Subject ID #* First 2. Date of Birth* MM slash DD slash YYYY 3. Sex (based on biological anatomy):* a. Male b. Female 4. Racial/Ethnic Identity (as defined in the US Census). Please choose one unless you acknowledge more than one category:* a. Asian/Pacific Islander b. Black/African American c. Caucasian/White d. Middle Eastern or North African e. Native American/Alaska Native f. Native Hawaiian or Other Pacific Islander 5. Are you of Hispanic, Latino or Spanish Origin?* a. Yes b. No 6. Do you currently have or are you experiencing any of the following? (choose all that apply)* a. open sores, puss and/or injury on the scalp b. skin cancer c. chemotherapy treatments d. total baldness e. none of the above 7. Are you currently taking antibiotics, or have you taken them within the last month?* a. Yes b. No 8. Are you on or have you had hormone therapy, within the last 2 years?* a. Yes b. No 9. On a scale from one (1) – ten (10), how would you rate your typical stress level? Level one is stress free and level ten is your breaking point.* 1 (Everything is easy/breezy) 2 3 4 5 6 7 8 9 10 (I feel like I’m about to burst) 10. Considering the hair that naturally grows from YOUR scalp, do you currently have any of the following? Select all that apply.* a. Relaxed hair (this includes a texturizer) b. Keratin-treated hair c. Color-treated hair (rinses, semi-, demi- or permanent color) d. Untreated hair that is free from any type of treatment mentioned above e. Naturally curly hair f. None of the above 11. What is your normal hair cleansing frequency?* a. daily b. 4 to 6 days per week c. 2 to 3 days per week d. 1 day per week e. Every 2 to 3 weeks f. Every 4 to 5 weeks g. Every 6 to 8 weeks h. Every 2 to 3 months i. Every 4 to 6 months j. I do not shampoo my hair 12. At what place or establishment is your scalp swabbing being performed?* a. In a doctor’s office b. At a salon or trichology office 13. What is the length of the natural hair that biologically grows from your scalp when pulled straight? (Please consider the region of your head where the scalp is being swabbed.)* a. Less than half an inch b. Between 0.5 and 2 inches c. Between 2 and 5 inches d. Between 5 to 8 inches e. Longer than 8 inches 14. On a scale from one (1) – ten (10), how would you rate the density of your hair? Level one is sparse and level ten is very dense.* 1 (I can readily see my scalp through my hair strands) 2 3 4 5 6 7 8 9 10 (I have TOO MANY hair fibers) 15. Which of the following statements apply to you as it pertains to your normal grooming regimen? Please select all that apply and if you do not know, do not select the statement.* a. I use a regular shampoo to cleanse my hair (as compared to a sulfate-free shampoo) b. I use a sulfate-free shampoo to cleanse my hair c. I co-wash my hair (the use of conditioners to clean the hair) d. I use a blow-dryer to dry my hair e. I use a hooded dryer to dry my hair f. I let my hair air dry g. I use a rinse-out conditioner h. I use a leave-in conditioner i. I use styling products on my hair after washing (styling products are oils, creams, mousse, gels, waxes, hair sprays, etc.) j. I use an over-the-counter medicated shampoo and/or product to control scalp flaking k. I use a prescription medication to control scalp flaking l. I apply products directly to my scalp such as oils, ointments, creams, etc. 16. Primary hair style: (the way that you wear your hair most of the time) Choose one.* a. Loose without much tension or pulling b. Pulled back into a pony-tail(s), buns, or rolls c. Braids or twists along the scalp such as cornrows/French braids d. Loose with some braids or twists along the scalp such as cornrows/French braids e. Individual braids or twists f. Extensions, weaves, or wigs that require the use of purchased hair to add to your existing hair g. Bantu knots h. Partial shave/buzz 17. Secondary hair style: (the second most frequently worn style) Choose one.* a. Loose without much tension or pulling b. Pulled back into a pony-tail(s), buns, or rolls c. Braids or twists along the scalp such as cornrows/French braids d. Loose with some braids or twists along the scalp such as cornrows/French braids e. Individual braids or twists f. Extensions, weaves, or wigs that require the use of purchased hair to add to your existing hair g. Bantu knots h. Partial shave/buzz 18. Consider the following hair accessories and select ones you use occasionally or daily as a part of your normal grooming regimen. If you do not know what an item is, please do not select it.* a. Rubber Bands b. Scrunchies c. Hair Bands/Head Bands d. Hair Clips e. Hair Pins/Bobby Pins f. Barrettes g. Ribbons h. Rollers i. Other j. I don’t use any hair accessories 19. Do you wear a scarf, bandana, cap or other head covering on a regular basis (for at least 6 hours daily)?* a. Yes b. No 19.1. If yes, indicate the type and material of the head covering.* 20. Do you take supplements for hair growth and enhancement?* a. Yes b. No 20.1. If yes, provide the name and brand on the following line.* 21. On a scale from one (1) – ten (10), please rate the amount of scalp flaking (dandruff) you experience. Level one means that you don’t have a problem and level ten represents the highest degree of uncontrollability.* 1 (I never see flakes) 2 3 4 5 6 7 8 9 10 (It’s like a blizzard on my shoulders when I move my head) 22. What is the current state of your hair?* a. I have a style where I add additional hair to my existing hair in the form of a weave, extensions, wig, hair piece or implants. b. I have a hair style where I DO NOT add additional hair to my existing hair. Thus, I do not wear weaves, extensions, wigs, hair pieces or hair implants. 23. Considering the current state of your hair and your current styling preference, do you have or use any of the following? Please select all that apply.* a. 100% human hair weave (according to what is written on the label/package) b. 100% synthetic hair weave (according to what is written on the label/package) c. Individual braids d. Cornrows or French braids e. Glue on the scalp to hold the weave tracks or weft f. 100% human hair piece g. Synthetic hair piece h. Hair implants from different areas of my scalp 23.1. Type and brand of hair that you use:* 23.2. Length of time you have had the CURRENT prosthesis in your hair (“CURRENT” refers to the last time additional hair was added to the hair that grows from your scalp. In other words, please consider the time your hair was loose before having hair added and it was freshly done).* a. Less than a week b. Between 1 week and 2 weeks c. Between 2 weeks and 4 weeks d. Between 4 weeks and 6 weeks e. Between 6 weeks and 8 weeks f. Between 8 weeks and 10 weeks g. Between 10 weeks and 12 weeks h. Longer than 12 weeks 23.3. How many times have you cleansed your hair since you have installed your CURRENT weave, extensions, wig, or hair piece?* a. Zero (0) b. 1 – 2 c. 3 – 4 d. 5 – 6 e. 6 – 8 f. More than 8 g. I don’t know 24. Do you have hair loss from your scalp that is resulting in reduced density?* a. Yes b. No 25. What was your age when you first started experiencing hair loss? (Please select one)* a. Before the age of 11 b. 11 – 15 years old c. 16 – 20 years old d. 21 – 25 years old e. 26 – 30 years old f. 31 – 35 years old g. 36 – 40 years old h. 41 – 45 years old i. 46 – 50 years old j. 51 – 55 years old k. 56 – 60 years old l. 61 – 65 years old m. 65 – 70 years old n. 71 – 75 years old o. Over the age of 75 26. If you are aware of close family members who also have hair loss, please indicate how they are related to you. Choose all that apply.* a. Mother b. Father c. Sister d. Brother e. Maternal Grandmother f. Paternal Grandmother g. Maternal Grandfather h. Paternal Grandfather i. I’m not aware of family members who have hair loss 27. What methods do you use to resolve your hair loss problem? (choose all that apply)* a. Physician/Dermatologist b. Licensed hair professional such as a barber or stylist c. Trichologist (a professional who has received specialized education in hair and scalp health after receiving his/her beauty license) d. Chiropractic e. Internet searches f. Self-administered natural remedies g. Spiritual or religious guidance h. Other i. I do not seek help 28. Please indicate the type of hair loss you have. If you don’t know, please select “I don’t know.”* a. Scarring b. Non-scarring c. I don’t know Hidden29. Using the diagrams below, please indicate where you have hair loss on your scalp by drawing circles. If there is more than one area, please choose more than one. a. Left View b. Right View c. Back View d. Top View Δ
