Please help us providing you more information regarding hair pulling to help you break the habit.  Here is a questionnaire that will take you just a few minutes to answer.  Your participation will help to generate more reliable and complete information, which we will share upon completion. 





Gender: (    )Male     (     ) Female


1.)                Mention the sites of your body from which you pull hair (head, face, eyebrow, etc.) If multiple sites, mention all the sites in that order from “most often” to “least often” :



2)         List the locations where you happen to be when you pull (such as school, home, work, etc):



3)         What activities are you engaged at the time you start pulling (reading, studying, writing, grooming, sitting etc.)?


4)         a)Identify your emotions, thoughts and feelings just BEFORE you pull:  , during and after pulling (angry, anxious, worried, frustrated, bored, etc.):



b) Identify your emotions, thoughts and feelings DURING hair pulling:    



c) Identify your emotions, thoughts and feelings AFTER pulling:



5)      How long have you been pulling (months/years)?


How did hair pulling begin?


6)  How long do you pull once you begin?


7)      At what point of hair pulling, do become aware you have been pulling (before I start pulling, in the middle, towards the end, etc.)


Who lets you know that you are pulling?


8)      Do you pull strand by strand or do you pull in chunks?


9)      Do you eat hair after pulling?


10)  Have you or are you diagnosed with a clinical disorder?


a.       If yes what and by whom?


11)  Do you pull specific types of hair (e.g. curly, wavy, discolored, etc)?

a.       If yes please specify

12)       Do other family members pull?

b.      If yes please specify who?


13) What have you done in the past to stop the habit of pulling?




14) Please share what you have figured out regarding why you pull hair? 



15) Do you or have you had any other automatic habit or tension releasing behaviors such as nail biting, picking, cutting or poking yourself?