MEDICAL HISTORY FORM
Personal Information
(Please complete the following fields and submit to share your medical history details with us)
Name
*
First Name
Last Name
Phone Number:
*
*please add your country code too
Birth Date:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
*
example@example.com
Questionnaire
Do you have any health problems?
*
Yes
No
If your answer is "yes", fill the gap with your health problems.
Are you currently taking any medication, either long-term or short-term?
Yes
No
If your answer is yes, please list the medication(s) you are currently taking:
Do you have problems with your heart or blood pressure?
*
Yes
No
If your answer is "yes", what kind of problems do you have?
Have you undergone any other surgical operations?
*
Yes
No
If your answer is "yes", what kind of surgeries have you undergone?
Do you have any allergies to any medicine or food?
*
Yes
No
If your answer is "yes", what kind of alergies do you have?
Have you developed alopecia areata (spot baldness)?
*
Yes
No
If your answer is "yes", how long ago did it first appeared?
Do your wounds heal normally?
*
Yes
No
Do you have a sexually transmitted disease (HIV, hepatitis, etc.)?
*
Yes
No
If your answer is "yes", which transmitted diseases do you have?
Have you had local anesthesia at a dentist?
*
Yes
No
Have you ever used recreational drugs?
*
Yes
No
If yes, which substances?
When was the last time you used them?
If you are 45 years of age or older, or if you experience heart problems, please forward this document to your cardiologist or family doctor, as we require their approval for you to proceed with the hair transplant, and return it to us once completed.
Patient's signature:
*
Doctor's signature:
Thank you!
Submit
Should be Empty: