Xpress Health Urgent Care / Berkley Urgent Care / Express Health Urgent CareNutrafol® Patient Screening Questionnaire
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Interest in Nutrafol
Hair thinning
Hair shedding/hair loss
Postpartum hair changes
Stress-related hair loss
Multivitamin/Nutritional support
Are you currently taking any of the following blood thinners?
Warfarin (Coumadin)
Eliquis
Xarelto
Pradaxa
Savaysa
Plavix
Daily Aspirin
Brilinta
Effient
Lovenox
None
Medical History / Relevant Conditions:
Current Medications:
Any planned surgery, dental, or cosmetic procedures within 30 days?
Yes
No
Provider Review
Appropriate Candidate
Candidate with Counseling
Not Appropriate
Submit
Should be Empty: