Questionnaire Name E-mail address Are you completing this on behalf of a child Sex Male Female What age did you start pulling? Country District What usually triggers a pulling spree for you? What usually helps you to stop pulling? Have you ever been pull free for any period of time? If so, how did you achieve this status and how long for? Please tick where you pull from. Select as many options as apply to you. Eyebrows Lashes Legs Beard Scalp Chest Pubic region Hands and/or feet Underarms Dog/s Cat/s Other pets Nose and ear hair Other people Was your father present when you were growing up? Did the start of your pulling coincide with your parents’ divorce or separation? Yes No N/A Do you have a difficult relationship with your parent(s) Mother Father Both None Were you : Emotionally abused as a child physically abused as a child Sexually abused as a child What memorable events occurred in your life the year you started pulling? Would you say your trich was at its worst during winter months? Have you ever been prescribed medication for trich? If so, please name the brand and state whether you found it successful. This data will be analysed and used to help others decide whether or not to take such medication. Doctor’s approach to trich? Good Poor Excellent Helpful Unhelpful I have never mentioned it to my doctor Were you hyperactive as a child Yes No Do you have ADD (Attention Defecit Disorder) Have you ever been diagnosed as having any other disorder or condition? If so, which? Do you have a partner/spouse No Yes Do you have a supportive and loving partner? Yes No Are you gay? No Yes How have previous partners responded to your trichotillomania, if you have told them. Well Poorly Mixed Response I have only had one partner and am still with them. Never mentioned it Did/does trichotillomania affect your ability to interact and to find a partner? Yes No Do you wear a wig? If so, do you wear synthetic or real hair? I do not wear a wig Real Hair Synthetic Hair Approximately how much money per month do you spend on trich related purchases, such as wigs, bandanas, scarves, hats, eyeliner, false lashes etc? 0 10 20 30 50 70 100 120 150 170 200 250 300 350 500 If you found this site through a search engine, which search engine did you use and what did you type as your search criteria? Are you a shy person? Who do you pull in front of? (If everyone, just tick anyone, not all boxes!) Partner Spouse Children Parents Close family Friends Anyone as I can’t control it. Nobody sees me pull. Other Do you : Munch the white hair follicle. Eat the whole hair Discard the hair (only select this option if none of the others apply) Rub hairs on your face/stomach/lips Look at the white hair follicle Collect certain types of hairs together Store hairs in a specific place, such as under the bed.(please explain below) Other (please explain) Convince yourself you will stop when you find the “right” hair. When did you first look at trich related sites on the Internet? How did you feel when you first noticed other trichsters were out there? Which sites do you find most helpful? Please list one url per line. What do you think of this website? Have you found friends with trich on the Internet? Yes No Would you like a trich buddy? Please check out the buddy rules. By ticking this box you agree to your email address being passed to a potential buddy. We will not release it to anyone else. Buddy Statement (state why you would be a good buddy & what type of person you would like as your buddy. (Ignore if you have not applied for a buddy) Do you attend any trichotillomania related clinics or events? Yes No Would you be interested in attending events etc. Do many of your friends know you have trich? Yes No What is your astrological star sign? Select Star Sign Aries Taurus Gemini Cancer Leo Virgo Libra Scorpio Sagittarius Capricorn Aquarius Pisces What is your date of birth? Select Day 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 Select Month January Febuary March April May June July August September October November December Select Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Career (if any) Do you feel that your trich has held you back with regard to your career? Yes No Do you find it easy to express anger? Yes No Do you find it easy to get close to people? Yes No May we contact you (this is likely to be very infrequent and we will not pass your data to anyone else) to advise of updates and events in the trich world? If so, should we use this e-mail address? Telephone number or address may be supplied if you prefer. Currency Select Currency Australian Dollar Brazilian Real Canadian Dollar Czech Koruna Danish Krone Euro Hong Kong Dollar Hungarian Forint Israeli New Sheqel Japanese Yen Malaysian Ringgit Mexican Peso Norwegian Krone New Zealand Dollar Philippine Peso Polish Zloty Pound Sterling Singapore Dollar Swedish Krona Swiss Franc Taiwan New Dollar Thai Baht Turkish Lira U.S. Dollar Are there any questions which you feel we have missed out and would like to see added to this questionnaire? Please tick this box if you do not wish to receive an occasional (possibly bi-monthly) email with updates on trich treatments or if your email is not private and you don’t want us to contact you. We do not spam and we won’t pass your email address to anyone else. NOTE … IF YOU TICKED THE BOX ABOVE, YOU WON’T RECEIVE A BUDDY BECAUSE WE WON’T BE ABLE TO CONTACT YOU TO TELL YOU ABOUT IT. We also need your date (including year) of birth if you want a buddy, so we can match your ages). Thank you so much for your time! Welcome to the Site. Press submit and wait. Please don’t submit your questionnaire more than once. Thank you.
