Medical History Form - Dr. Andre Nel Hair Restoration Clinic

Medical History Form

Dr. Andre Nel - Hair Restoration Clinic
Full Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
What is your age?
What is your gender?
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
PPS Number
This number will be used to open your encrypted consultation report, which will be sent to you following the consultation.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation / Work
General Practitioner (GP):
GP's Address:
Next of Kin:
Relationship
Name
Address
Phone
Do you have any allergies?
Please list them.
Are you currently taking any medication?
Please list them along with the doses:
Check the conditions that apply to you:
Other (Describe):
How often do you consume alcohol?
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
I provide my consent for the HSW Clinic to record my personal data & medical information.
Should be Empty: