Hair Loss Patient 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 NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employment Status - Employer? Self-Employed? Retired?
Emergency contact

Full NamePhone Number
ParentSignificant OtherSiblingChildFriendOther
MEDICAL HISTORY
Please list all current Medical Conditions:
YesNo
If YES, please list all prescription medications and / or supplements you are currently taking ?
YesNo
YesNo
YesNo
If YES, please list any known allergies
Surgical History
Additional Comments
YesNo
YesNo
YesNo
YesNo
YesNo
YesNoOther
If YES, please explain:
YesNo
YesNo
YesNo
YesNo
HAIR LOSS MEDICAL HISTORY
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Rogaine/minoxidilPropecia or finasterideAvodart or dutasteridePlatelet-Rich-Plasma (PRP) or Stem CellsHair TransplantOther
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:

Hair Loss Evaluation- Intake Form