Medical History Form

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Hair loss consultation

Email *

Untitled Title

Full Name *

Contact Number *

Age

Birth Sex

Female

Male

Clear selection

Civil Status

Single

Married

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Contact Numbers

How did you find out about us? *

Occupation

Occasionally the Asian Hair Restoration Center have items of interest such as new techniques or medications. Would you like to have notices such as these sent to your home or email address?

Yes

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How long have you been having Hair Loss?

Are you using any medications for hairloss?

Yes

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If yes, please list medications used for hairloss

Is your Father Bald? If yes, please select from the picture the baldness pattern *

Not Bald

III

III Vertex

VII

Is your Mother Bald? If yes, please select from the picture the baldness pattern *

Not Bald/Female

III

Is anyone in your mother's family bald? If yes, please select from the picture the baldness pattern *

Not Bald

III

III Vertex

VII

Is any of your Male siblings bald? If yes, please select from the picture the baldness pattern *

Not Bald

III

III Vertex

VII

For Male Patient - Are you bald? If yes, please select from the picture the baldness pattern *

Not Bald/Male

III

III Vertex

VII

For Female Patient - Are you bald? If yes, please select from the picture the baldness pattern *

Not Bald/Female

III

Have you ever had any of the Following?

Yes

Reactions or allergies to local anesthetics such as those used by a dentist?

Fainting of Fainting spells?

Do cuts in your wounds heal with normal Scars?

Do you require more "freezing or numbing" at your dentist?

Bad reactions to any substances applied to your skin

Bad reactions to Librium, Valium, steroids, antibiotics, or stitches?

Clear selection

Have you ever had any previous Cosmetic Surgery? if yes please list down.

Date of last Executive Checkup?

YYYY

Last PSA Value

Do you have a History of: *

Yes

Bleeding Problems (nose bleeds, gum bleeds, easy bruising, anemia )

Poor or abnormal healing ( wide scars, raised scars, large scars, keloids, slow healing)

Ophthalmologic (Eye Problems, cataract, glaucoma) Y N

Ear Problems (Ear aches, abnormal discharge, decrease hearing)

Liver Problems (hepatitis A, B, C)

High Blood pressure

Heart Disease ( heart attack, chest pain, arrhythmia, irregular pulse, murmur, rheumatic fever)

Lung Disease (asthma, pneumonia, chronic bronchitis, pleurisy)

Hormonal Disease ( diabetes, thyroid problems, etc.)

Kidney, Bladder disease, prostate problems

Stomach disease (ulcers, heart burn)

Neurologic Disease (Stroke, seizure, fainting, epilepsy, meningitis, neuralgia, migraine)

Hay fever, hives, eczema

Glaucoma

Do you have any artificial joints, valves, metal pins

Disorders of the immune system (arthritis, joint pains)

Tattoos

Blood Transfusions

Venereal/ Sexually Transmitted Diseases (HIV)

Emotional Problems (depression, anxiety, panic disorder, etc.)

Rare disorders (hereditary angioedema, Malignant hyperthermia)

Do you require more anesthetic solutions than most people?

Yes

Bleeding Problems (nose bleeds, gum bleeds, easy bruising, anemia )

Poor or abnormal healing ( wide scars, raised scars, large scars, keloids, slow healing)

Ophthalmologic (Eye Problems, cataract, glaucoma) Y N

Ear Problems (Ear aches, abnormal discharge, decrease hearing)

Liver Problems (hepatitis A, B, C)

High Blood pressure

Heart Disease ( heart attack, chest pain, arrhythmia, irregular pulse, murmur, rheumatic fever)

Lung Disease (asthma, pneumonia, chronic bronchitis, pleurisy)

Hormonal Disease ( diabetes, thyroid problems, etc.)

Kidney, Bladder disease, prostate problems

Stomach disease (ulcers, heart burn)

Neurologic Disease (Stroke, seizure, fainting, epilepsy, meningitis, neuralgia, migraine)

Hay fever, hives, eczema

Glaucoma

Do you have any artificial joints, valves, metal pins

Disorders of the immune system (arthritis, joint pains)

Tattoos

Blood Transfusions

Venereal/ Sexually Transmitted Diseases (HIV)

Emotional Problems (depression, anxiety, panic disorder, etc.)

Rare disorders (hereditary angioedema, Malignant hyperthermia)

Do you require more anesthetic solutions than most people?

Please list history of any other medical illness not mentioned above and include the treatment

Please list history of previous hospital admissions

Please check the medications you are currently on *

Aspirin

Vitamin E

Coumadin

Clopidogrel

NSAIDS (ex.Mefenamic acid, Ibuprofen)

Ticlopidine

Warfarin

Heparin

Other:

Required

List all prescription and non-prescription medications, vitamins and supplements that you are using which are not mentioned above

Do you have any Allergy to these medications? *

Antibiotics

Anesthetics

Pain Relievers

Anti - Inflammatory

Ointment or cream

Other:

Required

Indicate the Names of the drugs above that you have allergies to

Weekly Alcohol intake

Weekly Cigarrete Use

Other drugs

Do you smoke?

Yes

Clear selection

How many packs per day?

Have you tried to quit?

Yes

Clear selection

Can you go an 8 hour period without smoking?

Yes

Clear selection

How many packs did you smoke in a day?

If you have quit smoking, when did you quit? what did you use to help you quit smoking?

Pertinent Family History

Cancer

Tuberculosis

Diabetes

Heart Disease

Hypertension

Stroke

Epilepsy

HIV

Hepatitis

Jakob Kurtzfeld

Other:

What treatment interests you the most? *

Non - Surgical / Medical

Regenera Activa

Platelet Rich Plasma

Scalp Micropigmentation

Hair Transplant

Strip

FUE

Required

Other Comments and Suggestions

Preferred Teleconsultation platform(viber, whatsappp, skype, messenger, zoom) also please list down your contact details there *

Do you consent to Teleconsultation? *

I Consent to Teleconsultation

Required

I attest that all information given above is accurate and correct information *

True

Required

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