Medical Questionnaire Patient Name*First and SurnameAddress* Street Address Town/City Postcode Date of Birth* DD MM YYYY Mobile Number*Email Address* OccupationThis information will help us to assess your individual medical requirements and aftercare advice. Medical HistoryDo you have any of the following medical conditions?*Heart Condition, Diabetes, Liver/Kidney Complaint, Blood Disorder or Allergies?YesNoPlease include details:Have you had any other serious illnesses or operations in the past?*YesNoPlease include details:Do you have any skin conditions?*Examples: Keloid, Psoriasis YesNoPlease include details:Are you allergic to any medicines or other substances?*YesNoPlease include details:Please list any medicines/tablets you are currently taking:Do you take any blood thinners (e.g. aspirin, clopidogrel, warfarin, apixaban, dabigatran)?*YesNoAre you a smoker?*YesNoE-CigaretteAverage cigarettes per day:Do you drink alcohol?*YesNoHow many units per week?Wine: 125ml glass = 1.5 units, 250ml glass = 3 units Lager/Beer/Cider: Pint = 3 units Spirits (single small shot) = 1 unit Your Hair Loss History When did you first notice you were losing hair?*Has your hair loss started within weeks or over a longer period of time?Does anyone in your family suffer from hair loss?*YesNoI don't knowWhat side of the family? Father's side Mother's side Have you tried any hair loss treatments before?*YesNoPlease list examples:Examples: Finasteride (Propecia), Dutasteride (Avodart), Minoxidil (Regaine), Derma Rolling, PRP, HRP, Vitamins or Supplements. Have you had any previous hair loss procedures?Any special dietary requirements?Patient Hair Photos Please upload several photos for your medical file.Patient Photos* Drop files here or Data Collection* * I consent to my submitted data being collected and storedThe submitted data is used solely for the purpose of your surgeon, other health professionals involved in your care and Hair Repair Clinic to help ensure that you receive the best possible care. Your data is not shared with any other organisation or third party.