If you are going to be treated at our clinic please fill in this application form.
Primary consideration of your case is free.

The fields with asterisk (*) are obligatory

How did you Find us (if by the Internet please indicate search engine):

* Your Age:

* Gender:

Male: Female:

The age when the first patch of hair loss occured:

The age when significant part of your scalp hair was affected:

* Total duration of the disease:

less than one year less than 5 years more than 5 years

I took the following medicines for Alopecia treatment according to doctor's prescription:

Prednizone or/and other steroid hormones as system (oral) treatment:

Yes No

If Yes, please write down the names:

Cytostatics:

Yes No

I was treated by:

Injections of corticosteroids directly onto and around the bald area(s)	Yes No
PUVA-therapy	Yes No
Have you got topical sensitizing therapy?	Yes No

If you do not know how to classify medicines and treatments just write them down:

I suntanned much with uncovered head for long periods of time:	Yes No
I wear a wig all the time:	Yes No
My finger and thumb nails have changed:	Yes No
My pubis and armpits are hairless:	Yes No
Question for Alopecia universalis sufferers only Have your finger and thumb nails changed:	Yes No

If yes, when in the course of the disease did your finger and thumb nails change (indicate details, if possible):

Have you ever noticed short hair (up to 6-8mm long) with thicker outer ends in the affected areas of the scalp (like the shape of exclamation mark)?

Yes No

If yes, in what period of the disorder:

The first bare patch appeared at the edge (hair line) of the scalp:	Yes No
The first bare patch appeared at the back of the head	Yes No

Please fill in any other questions, or comments:

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