Hair Loss Evaluation Intake Form

Hair Loss Evaluation- Intake Form

The medical information you supply is subject to ALL patient/doctor privilege laws
Date of Birth *
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number *
Please enter a valid phone number.
Employment Status - Employer? Self-Employed? Retired?
Emergency contact

Full Name Phone Number
Relationship to patient

Parent Significant Other Sibling Child Friend Other
MEDICAL HISTORY
Please list all current Medical Conditions:
Do you take any prescription medications?

Yes No
If YES, please list all prescription medications and / or supplements you are currently taking ?
Do you currently take oral Propecia, Proscar, Finasteride, Avodart or Dutasteride?

Yes No
Do you currently take oral Nizoral (ketoconazole) or Sporanox (itraconazole)?

Yes No
Do you have any known allergies?

Yes No
If YES, please list any known allergies
Surgical History
Additional Comments
Do you Smoke

Yes No
Do you consume alcoholic beverages?

Yes No
Do you use marijuana, cocaine or other similar drugs?

Yes No
Do you have or are you being treated for glaucoma (increased intra-ocular eye pressure)?

Yes No
Are you allergic to Rogaine?

Yes No
Are you allergic to steroids, corticosteroids or hydrocortisone?

Yes No Other
If YES, please explain:
Do you have any skin conditions on your scalp such as eczema, psoriasis, red inflamed painful scalp conditions?

Yes No
Do you presently have liver disease, liver function abnormalities, hepatitis or any medical disorder of liver function including, but not limited to cirrhosis of the liver, liver cancer, jaundice etc.?

Yes No
If male, do you have BPH (benign prostate hypertrophy) or have you been diagnosed with prostate cancer?

Yes No
Are you currently being treated for cancer?

Yes No
HAIR LOSS MEDICAL HISTORY
Do you suffer from Male Pattern Hair loss?

Yes No
Are you experiencing SUDDEN hair loss unrelated to male pattern hair loss?

Yes No
Is your hair loss due to the side effects of medications or chemotherapy or nutritional disease or thyroid disease?

Yes No
Is your hair loss due to chemical treatment of your hair such as perms or relaxing or coloring or from hairstyle such as cornrowing or ponytail?

Yes No
Are you using any medicines on your scalp?

Yes No
Have you been treated for hair loss?

Yes No
Check each treatment that you have undergon

Rogaine/minoxidil Propecia or finasteride Avodart or dutasteride Platelet-Rich-Plasma (PRP) or Stem Cells Hair Transplant Other
If other, please list
At what age did you first notice hair thinning?
Please describe your history of hair loss:
Please from the illustration and description below, choose which Norwood Classification or Hair Loss best describes your present condition:
Please select your current Norwood Classification:
Should be Empty:

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Hair Loss Evaluation- Intake Form