Medical Questionnaire Patient Name*First and Surname Address* Street Address Town/City Postcode Date of Birth* Day Month Year 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? Yes No Please include details:Have you had any other serious illnesses or operations in the past?* Yes No Please include details:Do you have any skin conditions?*Examples: Keloid, Psoriasis Yes No Please include details:Are you allergic to any medicines or other substances?* Yes No Please include details: Please list any medicines/tablets you are currently taking: Do you take any blood thinners (e.g. aspirin, clopidogrel, warfarin, apixaban, dabigatran)?* Yes No Are you a smoker?* Yes No E-Cigarette Average cigarettes per day: Do you drink alcohol?* Yes No How 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?* Yes No I don't know What side of the family? Father's side Mother's side Have you tried any hair loss treatments before?* Yes No Please 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 Select files Max. file size: 512 MB. 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.
