Application for Survey about Alopecia

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Email *

Be the one to make a difference in the future of medicine!

How did you hear about this opportunity? Please do not say "FACEBOOK".. Please type either the page name where you saw this or the name of the person who posted the opportunity that prompted you to sign up. *

What is your first name? *

What is your last name? *

What is your email address? *

What is your cellular telephone number? *

Which city do you live in *

Which state do you live in? *

How old are you? *

Are you, or is any immediate family member, employed by or affiliated with any pharmaceutical or biotechnology company, or working in market research?

Yes

What is your gender identity? Please select one response below.

Male

Female

Non-binary

Prefer not to answer

Which of the following conditions, if any, have you been diagnosed with by a doctor? Please select all that apply.
*

Alopecia

Atopic Dermatitis

Eczema

Nail Pitting

Psoriasis

Vitiligo

Anxiety

Depression

Rheumatoid or Psoriatic Arthritis

Diabetes

Asthma

Thyroid Disease

Allergic Rhinitis

Anemia

None of the above

Required

And what type of Alopecia have you or your child been diagnosed with? Please select one response.
*

Alopecia Areata (patchy or total hair loss)

Alopecia Areata Ophiasis (hair loss including the sides and lower back of the scalp)

Alopecia Totalis (total scalp hair loss without body hair loss)

Alopecia Universalis (total scalp hair loss with total body hair loss)

Androgenetic Alopecia (male / female pattern baldness)

Scarring Alopecia (loss of hair which is accompanied with scarring)

This does not apply to me, I have a child with Alopecia

Where has your or your child's Alopecia Areata caused hair loss? Please select all that apply.
*

This does not apply to me, I have a child with Alopecia

Scalp

Eyebrows

Eyelashes

Body / Other areas

Beard / mustache [MALE ONLY, S02=1]

Required

What is the current proportion of hair on your scalp you or your child have lost due to Alopecia Areata, and what is the most hair you have ever lost? Your best estimate is fine.

% of current hair loss *

______% maximum loss of scalp hair ever
*

We’re interested in understanding how your Alopecia Areata has changed over time. From your own perspective, what would you say is the severity of your or your child's Alopecia Areata?

Mild

Moderate

Severe

At initial diagnosis

At its worst

Today

What type of physician first diagnosed your or your child's Alopecia Areata?
*

Primary Care Doctor

Pediatrician

Dermatologist

Other:

Was the initial diagnosis of your or your child's Alopecia Areata confirmed by a dermatologist?

Yes

How many years ago were you or your child diagnosed with Alopecia Areata?
*

Is your or your child's Alopecia Areata and/or hair loss a result of chemotherapy?

Yes

Are you responsible for the care of any children between the ages of 12 and 17 years old who have been diagnosed by a doctor with the following? Please select all that apply. [RANDOMIZE]

Alopecia

Atopic Dermatitis

Eczema

Nail Pitting

Psoriasis

Vitiligo

Anxiety

Depression

Rheumatoid or Psoriatic Arthritis

Diabetes

Asthma

Thyroid Disease

Allergic Rhinitis

Anemia

None of the above

Required

And what type of Alopecia does this child have? Please select one response below
*

My child does not have Alopecia, I am the person with Alopecia

Alopecia Areata (patchy or total hair loss)

Alopecia Areata Ophiasis (hair loss including the sides and lower back of the scalp)

Alopecia Totalis (total scalp hair loss without body hair loss)

Alopecia Universalis (total scalp hair loss with total body hair loss)

Androgenetic Alopecia (male / female pattern baldness)

Scarring Alopecia (loss of hair which is accompanied with scarring)

What is the exact age of the 12–17-year-old child with Alopecia Areata? If you have more than one child with Alopecia Areata in this age range, please only think about your youngest one.

Type N/A if you do not have a child with Alopecia *

What is your relationship with this child? Please select one response below.
*

I do not have a child with alopecia

Parent

Aunt/Uncle

Grandparent

Sibling

What is the gender identity of this child?

Type N/A if you are the patient

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