Hair Transplant Medical History Form

Name *

First

Last

Age

Sex

Male
Female
Other

Can you send us your hair loss pattern?

1
2
3
4

Does any family member suffer from hair loss problems? (father, brother, uncle etc)

At which age did your hair loss begin?

Have you ever used a laser helmet?

Yes
No

Have you used biotin and zinc?

Yes
No

Have you used Minoxil Forte 5% skin spray?

Yes
No

Have you used Finasteride?

Yes
No

Have you done hair transplant procedures before?

Yes
No

If yes, How many times?

Which method did you have it done?

How many grafts they have worked with?

Have you undergone any surgical procedure before?

Yes
No

Do you Smoke?

Yes
No

If yes, how often do you smoke?

Do you consume alcohol?

Yes
No

Do you have any known diseases?

Yes
No

Do you have any contagious diseases? (HIV, HCV,..)

Yes
No

What is your diseases?

Do you suffer from psoriasis?

Yes
No

Do you have keloid scars?

Yes
No

Do you have Lupus?

Yes
No

Do you have Alopecia Areata?

Yes
No

IF YES have you visited a dermatologist previously?

Do you have a known allergy?

Is there a medicine you use continuously?

Are you using Aspirin?

Yes
No

This questionnaire you filled in and the information you provided will affect the course of treatment, check the correctness and check the box below. The information you provide is under guarantee for data security and cannot be shared with anyone other than your doctor. Based on the information you provided, your operation will be planned and a price quote will be given to you, so you will know and accept that there would be changes in the plans if the information given above is mistake or not true. I read it and approve it

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