Trichotillomania Questionnaire - Trichotillomania Support

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Trichotillomania

Support

for all BFRBs BFRBs are Body Focused Repetitive Behaviours such as hair pulling and skin picking.

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Treatment for BFRBs
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This questionnaire relates to trichotillomania, the skin picking questionnaire is here. If you have another BFRB, please contact us. Please take your time with the questionnaire and possibly have a break midway – talking about your hair pulling can be an emotional experience. We know it is a long one but it does help so much. We will never pass your details on to anyone else. Please let us know if you have any problems with the form.

Name

May we contact you? If you click no, then of course we can't give you a buddy.

Email - non-compulsory, but if you don't supply it, we can't buddy you up or check in on you

Are you completing this on behalf of a child?

How did you find the form?

Gender

Preferred pronouns

Did the start of your pulling coincide with your parents' divorce or separation?

Age when hair pulling started

Country

District

Triggers - please list what triggers your hair pulling

Have you ever been pull free? If so, how did you achieve this status and for how long?

Where do you pull from? Select as many options as apply to you

Eyebrows Eyelashes Scalp Beard Legs Arms Nose Chest Pubic region Hands Feet Pets

Times when you do not pull - what usually helps?

Date of birth

Were both parents present when you were growing up?

Do you have a difficult relationship with a parent or step-parent?

Abuse as a child

Abuse related information - what should we know?

What memorable events occurred in your life the year you started hair pulling?

Have you ever been prescribed medication for trichotillomania? 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.

Have you ever been diagnosed with any other condition or disorder, please list, thank you.

Doctor's approach to Trichotillomania

Hyperactive as a child

Are you a shy person?

Do you easily express anger?

Is it easy for you to get close to people?

Would you like a buddy?

What would you like to say about yourself, to your buddy (if you asked for one)

Rituals - select as many as apply