1. Are you above 18 years old?
* must provide value
Yes No
2. Do you have a diagnosis of alopecia areata affecting your scalp?
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Yes No
3. Which type of health professional has told you that you have alopecia areata? (check all that apply)
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Please specify other health professional that has told you that you have alopecia areata?
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4. Was the diagnosis of alopecia areata confirmed with a biopsy?
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Yes No Not sure
5. What type of alopecia areata do you have?
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Single patch of hair loss
Multiple patches of hair loss
Ophiasis type (sides and back of the scalp affected)
Alopecia totalis (entire scalp affected)
Alopecia universalis (entire scalp and entire hair body area affected)
Single patch of hair loss
Multiple patches of hair loss
Ophiasis type (sides and back of the scalp affected)
Alopecia totalis (entire scalp affected)
Alopecia universalis (entire scalp and entire hair body area affected)
6. Please categorise the total area of your scalp that is missing hair right now. (Areas of vellus hair, peach fuzz or baby hair, should also be considered as missing hair.)
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No missing hair (0% of my scalp is missing hair; I have a full head of hair)
A limited area (1-20% of my scalp is missing hair)
A moderate area (21-49% of my scalp is missing hair)
A large area (50-94 % of my scalp is missing hair)
Nearly all or all (95-100% of my scalp is missing hair)
No missing hair (0% of my scalp is missing hair; I have a full head of hair)
A limited area (1-20% of my scalp is missing hair)
A moderate area (21-49% of my scalp is missing hair)
A large area (50-94 % of my scalp is missing hair)
Nearly all or all (95-100% of my scalp is missing hair)
7. How old were you when you first developed alopecia areata (in years)?
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
8. Do you have nail changes which are associated with alopecia areata?
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Yes No Not sure
9. Has a doctor told you that you have any of the following medical conditions?
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10. What is your gender?
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Female Male Prefer not to say Female
Male
Prefer not to say
11. What is your ethnic origin?
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White
Black-African
Afro-Caribbean
African American
Asian- Chinese
South Asian
Asian-other
Hispanic or Latino
Unknown
Other (please specify)
Prefer not to say
White
Black-African
Afro-Caribbean
African American
Asian- Chinese
South Asian
Asian-other
Hispanic or Latino
Unknown
Other (please specify)
Prefer not to say
11.1 Please specify other ethnic origin
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12. What is your country of birth?
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--- Not in this country list (please specify) Afghanistan Oland Islands Albania Algeria Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo,the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia,Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Qatar R? union Romania Russian Federation Rwanda Saint Barth?lemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Vietnam Virgin Islands, British Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Please specify if your country of birth is not in the list
13. Number of years of schooling in general education:
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
14. What is your highest level of education?
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No high school diploma
High school diploma or equivalent
Associate's degree
Bachelor's degree or higher
No high school diploma
High school diploma or equivalent
Associate's degree
Bachelor's degree or higher
15. What further education or vocational training have you completed or are you doing now?
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Specific vocational training (< 1 year)
Specific vocational training (>1 year)
Other vocational training (please specify)
Tertiary level qualification / diploma
University degree (undergraduate)
University degree (post graduate)
Specific vocational training (< 1 year)
Specific vocational training (>1 year)
Other vocational training (please specify)
Tertiary level qualification / diploma
University degree (undergraduate)
University degree (post graduate)
15.1 Please specify what other vocational training you have completed or are doing now (please describe)?
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16. What is your usual/normal living situation now?
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17. What is your employment status?
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17.1 Please specify what is your other employment status?
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18. Marital status (from a legal perspective):
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Single/unmarried
Married
Divorced
Widow/widower
Separated
Not known
Other (please specify)
Single/unmarried
Married
Divorced
Widow/widower
Separated
Not known
Other (please specify)
18a. Please specify other marital status
19. How many days in hospital (if any) have you had in the last 3 months?
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
19a. How many of these days were related to alopecia areata?
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
Days spent in hospital for alopecia cannot be greater than total days spent in hospital!
20. How many days off work did you have in the last 3 months?
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
20a. How many of these days were related to alopecia areata?
* must provide value
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
Days off work for alopecia cannot be greater than total days off work!
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