---
title: "Hair Loss Evaluation Form - Free Form Template | Formswrite"
description: "Trichology intake to evaluate hair shedding, density, and scalp condition. 16 ready-to-use questions. Use this free template in Formswrite with one click."
canonical: https://formswrite.com/templates/hair-loss-evaluation-form
last-updated: 2026-10-11
---

# Hair Loss Evaluation Form

formswrite.com/templates/hair-loss-evaluation-form

## Hair Loss Evaluation Form

Trichology intake to evaluate hair shedding, density, and scalp condition.

Patient Information

Full name 

Your answer

Date of birth

Email

Sex assigned at birth

Hair Loss Profile

How long have you noticed hair loss?

Pattern of hair loss

\+ 8 more questions

## About this template

Trichology intake to evaluate hair shedding, density, and scalp condition.

### How does it work?

1.  Click **Use template**. We'll drop a copy into your Formswrite workspace - no setup needed.
    
2.  Tweak the questions, branding, and logic to fit your workflow. Add your logo, colors, and cover image.
    
3.  Publish and share the link, embed it on your site, or drop it into a chatbot widget. Responses stream straight to your dashboard.
    

Categories

[Health](/templates)

16 questions · Free

USE TEMPLATE

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