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
Date
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*
YesNoNot Sure
Please list them.*
YesNo
Please list them along with the doses:*
AsthmaHypertensionCardiac diseaseDiabetesCancerEpilepsyPsychiatric disorderNone
Other (Describe):
DailyWeeklyMonthlyOccasionallyNever
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: