Hair Loss Consultation | Bernstein Medical

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In-office ConsultationVirtual ConsultationSurgical Photo Assessment
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Date of Birth*

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Date
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Patient History

(If any aspect of your health changes in the future, please let us know)
New PatientFollow Up Visit
Address

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CityState / Province

Postal / Zip CodeCountry
Hair LossMedical TreatmentSurgical TreatmentRobotic FUEFUTEyebrow RestorationRepairScar RevisionPRPOther
Other hair loss/restoration consults and approximate dates:
2. Have you had previous Hair Restoration Surgery? If yes, please provide details including years.*
3. At approximately what age did your hair loss begin?
YesNo known allergies
AntibioticsNovocain or XylocaineAdrenalineValiumCodeineFood AllergiesHay Fever/Upper RespiratoryChromium or CollagenOther Allergy not listed
Please list.
Please specify other allergy/allergies not listed above.
HivesRespiratoryHeart PalpitationsSwelling of tongueRashCoughing & CongestionDifficulty BreathingOther reactionsNone
Please specify other reactions experienced:
YesNo
Please list.
YesNo
Start Date*

MonthDayYear
Date
YesNo
Please list.
Hepatitis or Liver DiseaseKidney ProblemsDiabetesAsthmaHigh Blood PressureHeart DiseaseIrregular Heart BeatsRheumatic FeverHIV/AIDSAnemiaThyroid DiseasePhlebitisUlcersGlaucomaSeizuresSleep ApneaFaintingBlood DisordersOtherNone of the above
Please explain:
AnxietyDepressionPanic DisorderObsessive Compulsive Disorder (OCD)Body Dysmorphic Disorder (BDD)HypochondriacOther Emotional/Drug/Psychiatric ProblemsNone of the above
Please explain:
OccasionalIntermittentPersistentNone
YesNo
Please describe:
YesNo
Indicate PSA number (if known)
Date of Test

MonthDayYear
Date
YesNo
Please list all medical problems and hospitalizations:
<5%5102030405060708090100%
SensitivityItchingTinglingNone of the above
TodayYesterday2 days ago3 days agoMore than 3 days ago
17. What is your height?
Please specify in feet and inches
18. What is your weight?
Please specify in lbs
YesNo
20. How many children do you have?
YesNo
Describe how much alcohol is consumed per day
YesNo
If Yes, how much?
YesNo
If Yes, results:
YesNo
If Yes, results:
Stretched ScarsRaised or thickened scarsKeloidsNo known problems with healing
YesNo
Please specify
YesNo
Please specify
YesNo
Please specify
YesNo
Please give details
Blood thinners (warfarin, heparin)Seizure medications (Dilantin)Gout (colchicine, alopurinol)Blood pressure medications (beta blockers, water pills)Thyroid Synthroid, L-Thyroxine)Anti-Inflammatories (prednisone)Cholesterol Lowering Lipitor)Oral contraceptivesFertility medicationsHormonesPsychiatric medications (i.e.: Lithium, anti-depressants, Prozac)CocaineAmphetaminesOther medications or drugs
Crash dietsAnorexiaBulimiaVegetarianOther Special Diet
Please describe.
PermsFlat Iron StraighteningChemical Straightening or relaxerBraidingHair ExtensionsWigsHair Systems
10. How often do you wash/shampoo your hair?
11. When was the last time you washed/shampooed your hair?
AnemiaIron DeficiencyB12 DeficiencyAutoimmune DiseaseSignificant Weight ChangeIncreased SweatingIncreased Feeling of Being Hot or ColdHigh FeverJoint PainSensitivity to SunlightHepatitis or Liver DiseaseKidney ProblemsDiabetesAsthmaHigh Blood PressureHeart DiseaseIrregular Heart BeatsRheumatic FeverHIV/AIDSThyroid DiseasePhlebitisUlcersGlaucomaSeizuresSleep ApneaFaintingAnemiaBlood DisordersOtherNone
Please describe.
AnxietyDepressionPanic DisorderObsessive Compulsive Disorder (OCD)Body Dysmorphic Disorder (BDD)HypochondriacOther Emotional/Drug/Psychiatric ProblemsNone of the above
Cystic AcneHirsutism (increased body or facial hair)Galactorrhea (breast secretions when not pregnant)Virilization (appearance of male traits i.e.: deepened voice)Infertility
YesNo
YesNo
YesNo
YesNo
Not MenopausalPerimenopauseMenopausePost Menopause
Hair TransplantationFace LiftBrow LiftOther scalp or facial surgery
YesNo
Please provide details including years
YesNo
Please list all medical problems and hospitalizations
<5%5102030405060708090100%
SensitivityItchingTinglingNone of the above
TodayYesterday2 days ago3 days agoMore than 3 days ago
26. What is your height?
Please specify in feet and inches
27. What is your weight?
Please specify in lbs.
YesNo
29. How many children do you have?
YesNo
Describe how much alcohol is consumed per day
YesNo
If Yes, how much?
YesNo
Results:
YesNo
Results:
Stretched ScarsRaised or thickened scarsKeloidsNo known problems with healing
YesNo
Please specify.
YesNo
Please specify.
YesNo
Please describe.
YesNo
Please give details.
What are your hair restoration goals?**
Have you had any hair transplants? Please provide details (i.e., dates and types)**
List relevant health info that might affect a surgical procedure (i.e. keloids, bleeding, diabetes).
YesNo
YesNo
Other medications?
Cause of Hair LossRobotic Hair Transplant (R-FUE)Follicular Unit Transplant (FUT)Eyebrow TransplantRepair Old Hair TransplantPlatelet Rich Plasma (PRP)Surgical TreatmentMedical Treatment
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