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Dermatology Hair Loss Questionnaire Mobile App

The Dermatology Hair Loss Questionnaire Mobile App provides dermatologists' information on your hair loss issues and covers related issues like hair care, scalp disease, medical health, menstrual history, family history and treatment. Use this app to improve quality of life when facing female pattern hair loss due to a hormone imbalance by finding the right hair loss treatment. Regardless of treatment type, receive useful information from board-certified dermatologists about skin and hair growth.

A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com.

If you would like to enable HIPAA on your GoCanvas account, please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save."

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Dermatology Hair Loss Questionnaire Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Name

  • Ico date

    Date

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    Chart

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    Age

  • Ico dropdown

    Sex

  • Ico multiline

    When did you first notice your problem?

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    Who first noticed your hair loss?

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    Did you first notice thinning or excess shedding?

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    Has your problem been slowly or rapidly progressive?

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    Has the problem been localized in patches or does it involve your entire scalp?

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    Do you think that the cause of your problem is increased shedding, hair breakage, or failure to g...

  • Ico textbox

    Do you think that you are losing more than 100 hairs a day?

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    Do you think that your hair grows slowly, fast, or not at all?

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    Has there been a change in the color, texture, waviness, brittleness, or thickness of individual ...

  • Ico textbox

    What is your natural hair color?

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    Do you consider your individual hairs to be thin, average, or thick?

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    Do you have straight, mild wave, or curly hair?

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    Has your hair become more unmanageable?

  • Ico textbox

    Do you have any excess facial or body hair?

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    Do other family members have excess facial or body hair?

  • Ico multiline

    How do you take care of your hair?

  • Ico textbox

    Do you have your hair professionally done?

  • Ico textbox

    How often do you shampoo?

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    Have you changed the frequency of shampooing?

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    What is your usual shampoo?

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    Have you recently changed shampoos?

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    Please CHECK any of the things listed you do to your hair and how often:

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    Put your hair in rollers

  • ...and More!

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