Medical Questionnaire Medical Questionnaire Full Name*Address* Street Address Town/City Postcode Date of Birth* DD MM YYYY Phone Number*Email* OccupationThis information will help us to assess your individual medical requirements and aftercare advice.Do you want us to inform your GP Practice?*You can have private treatments without informing your GP. The British Medical Association (BMA) does suggest informing your GP mainly because they know your medical history and can offer advice if necessary.YesNoGP Name and Practice Address Medical HistoryDo you have any of the following?Heart Condition, Diabetes, Liver/Kidney Complaint, Blood Disorder, Allergies or other?YesNoPlease include details:Have you had any other serious illnesses or operations in the past?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 have any skin conditions?Examples: Keloid, Psoriasis YesNoPlease include details:Are 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 MRSA InformationHave you ever been colonised or infected with MRSA before?YesNoDo you care or live with anyone who has had MRSA?YesNoHave you been a patient in a hospital with the last 6 months?YesNoDo you work in a healthcare environment?YesNoYour Hair Loss HistoryWhen 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:Finasteride / Propecia, Dutasteride or others including Minoxidil, RegaineHave you had any previous hair loss procedures?Any special dietary requirements?Patient Hair Photos Please upload several photos for your medical file. Data Collection* I consent to my submitted data being collected and stored We treat your information with respect. The submitted data is used by your doctor and your patient coordinator at Hair Repair Clinic. Your data is not shared with any other organisation or third party.
