Hair Loss Treatment Progress Tracker

Patient Information

Name: _________________________ Date Started: _____________

Initial Assessment

• Primary Hair Loss Pattern: □ Crown □ Temples □ Diffuse □ Other: _______
• Severity Scale (1-5): _____
• Current Hair Loss Rate: □ Mild □ Moderate □ Severe

Monthly Progress Log

Month 1-3

Date: ____________

• Treatment(s) Used: _________________________
• Side Effects (if any): ______________________
• Changes Observed:
  • Hair Density: □ Better □ Same □ Worse
  • Shedding: □ Decreased □ Same □ Increased
  • Photos Taken: □ Yes □ No

Month 4-6

Date: ____________

• Treatment(s) Used: _________________________
• Side Effects (if any): ______________________
• Changes Observed:
  • Hair Density: □ Better □ Same □ Worse
  • Shedding: □ Decreased □ Same □ Increased
  • Photos Taken: □ Yes □ No

Treatment Compliance

Mark each day treatment was used:

Week 1: □ M □ T □ W □ T □ F □ S □ S Week 2: □ M □ T □ W □ T □ F □ S □ S

Notes

Changes in diet/lifestyle: ____________________ Stress levels (1-10): _______ Other observations: ________________________

Next Appointment

Date: ____________ Time: ____________

Bring this tracker to each follow-up appointment