Patient Questionnaire for Hair Loss & Hair Transplant Consultation

Patient Questionnaire for Hair Loss & Hair Transplant Consultation

Please complete this questionnaire to help prepare for your hair loss and hair transplant consultation.
Patient Details and Treatment Preference
Your preferred treatment(s):
Full Name

First NameLast Name
Gender

Other
Date of Birth

MonthDayYear
Date
Height
Example: 180 cm
Weight
Example: 80 kg
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Do you have any underlying medical conditions?
(e.g., thyroid disorders, diabetes, hormonal conditions, autoimmune diseases, etc.)
Are you currently using any medications, supplements, or hormones?
Leave blank if not using any, otherwise list all that is being used.
Do you have any known drug, food, or substance allergies? (If yes, please specify.)
Diet, Weight & Lifestyle (select as a "yes")
Have you experienced any of the following in the past 3-6 months?
Hair Loss Information
Primary reason for consultation
Affected areas (you may select more than one)

Other
How long have you been experiencing hair loss?
Did it appear gradually or suddenly?
Female Patients
For Female Patients: (Only select if "Yes")
Male Patients
For Male Patients: (Only select if "Yes")
If yes, please specify the duration and dosage.
Family History
Do you have a family history of hair loss/thinning?
If yes, which family members have experienced hair loss/thinnig? Describe the pattern.
Example: Male/Female - Place in Family (Father, Mother, etc.) - Pattern (crown, hairline, etc.)
Have you previously used or undergone any of the following?
Have you previously undergone a hair transplant?
If yes, please provide details (year, technique, number of grafts, and any other relevant information)
Consultation Support and Referral Source
What are your expectations from hair transplant or treatment?
Results you hope to achieve, which areas concern you the most, etc.
Do you have any additional concerns or information you would like to share with the doctor?
Upload photos of your hair or scalp

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How did you hear about our clinic?
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Patient Questionnaire for Hair Loss & Hair Transplant Consultation

Patient Details and Treatment Preference

Medical History

Hair Loss Information

Female Patients

Male Patients

Family History

Consultation Support and Referral Source