---
title: Hair Loss Evaluation Form Template - Pre-Visit Symptom Assessment | Paperform
description: Professional hair loss evaluation form for healthcare providers. Assess hair loss patterns, scalp condition, and hormonal factors before consultations. Customizable template for dermatology and trichology practices.
url: "https://paperform.co/templates/hair-loss-evaluation-form"
type: static
generatedAt: "2026-03-28T00:44:03.216Z"
---

[← Back to free form templates](/templates/)    ![Hair Loss Evaluation Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/hair-loss-evaluation-form.png)
    [Preview](https://_preview.paperform.co/ai-template/hair-loss-evaluation-form) [Use this template for free](/create?ai-template=hair-loss-evaluation-form)    [Healthcare & Medical Forms](/templates/category/healthcare/)[Industry-Specific Forms](/templates/category/industry-specific/) [Healthcare](/templates/industry/healthcare/) [Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Healthcare Administrator](/templates/role/healthcare-admin/)     About this free form template
### Streamline Hair Loss Assessments with a Professional Evaluation Form

Hair loss concerns affect millions of patients, and a thorough pre-visit assessment can make all the difference in diagnosis and treatment planning. This **Hair Loss Evaluation Form** is designed for dermatologists, trichologists, endocrinologists, and healthcare practices that specialize in hair restoration to gather comprehensive patient information before consultations.

#### Why Use This Hair Loss Assessment Template?

Rather than spending valuable appointment time collecting basic information, this form allows patients to document their hair loss patterns, scalp condition, lifestyle factors, and medical history in advance. Healthcare providers receive structured, detailed data that supports accurate diagnosis—whether evaluating androgenic alopecia, telogen effluvium, alopecia areata, or hormonal imbalances.

The template covers essential assessment areas including hair loss duration and progression, pattern identification, family history, hormonal factors (thyroid conditions, PCOS, menopause), medications, stress levels, and scalp health observations. This holistic approach helps providers identify potential underlying causes and develop personalized treatment plans.

#### Perfect for Healthcare Practices and Specialists

This form template is ideal for:

 - **Dermatology practices** managing hair and scalp health
 - **Trichologists** specializing in hair loss treatment
 - **Endocrinologists** evaluating hormonal hair loss
 - **Hair restoration clinics** conducting initial assessments
 - **Primary care providers** screening hair loss concerns

Built with Paperform's intuitive platform, you can customize this template to match your practice branding, add your logo, modify questions for specific protocols, and embed it directly on your website. Conditional logic ensures patients only see relevant follow-up questions, creating a smooth, personalized experience.

#### Automate Your Workflow with Stepper

Connect this form to [Stepper](https://stepper.io) to automatically route completed assessments to your EHR system, schedule follow-up appointments, send pre-appointment instructions, or flag urgent cases for immediate review. Keep your practice running efficiently while providing excellent patient care.

#### Secure, Compliant, and Professional

Paperform is SOC 2 Type II compliant and offers robust security features to protect sensitive patient information. With custom branding options, you can create a professional, trustworthy experience that reflects the quality of your practice.
       Built for growing businesses, trusted by bigger ones.   Trusted by 500K+ business owners and creators, and hundreds of millions of respondents.     ![Capterra - 4.8 out of 5](/images/capterra-st.jpg)
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