Virtual Consultation Form

MrMrsMSDr

Please Answer the Following Questions

History of Current or Past Medical Problems/Conditions*

Please check any of the following conditions or diseases that you have or had in the past

Bleeding ProblemsDiabetesHeart DiseaseHIV/AIDSHepatitis (jaundice)Smoker

History of Past Surgeries (including cosmetic procedures)*

Medications You Currently Take*

Check any of the following as they apply

Aspirin or Similar DrugsNarcotic MedicationsAnabolic Steroids

When did you first notice your hair loss?

Within last year1-3 years ago3-5 years agoOver 5 years ago

What first drew your attention to your hair loss?

Comments from family & friendsI saw pictures of myselfI’ve been seeing excessive hair lossOther

What bothers you most about losing your hair?

Balding makes me look olderI feel less attractiveMakes me feel insecureOther

What concerns do you have about hair transplantation?

PainScarringCostOther

Have you tried other options?

RogainePropeciaHair PieceHair Transplant

What would be the best thing about having your hair back?

Look youngerFeel more attractiveFeel more confidentOther

Do you know the difference between the methods of hair transplantation?

YesNo

If yes, what was the source of information?

Emergency Contact

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