Hair Loss Intake

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Age* This field is required.
4
Gender* This field is required.
Male
Female
5
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Email* This field is required.
example@example.com
7
Phone Number* This field is required.
Area Code
Phone Number
8
Emergency Contact* This field is required.
Name / Relationship
Phone Number 1
Phone Number 2
9
Current Medication List (please list all medications that you are currently taking).List all medications currently prescribed to you by any doctor. This includes medications prescribed on a regular basis here, by your primary care physician, and any other doctor you see.
10
Drivers License Number* This field is required.
11
Driver License Picture upload (front)* This field is required. Please upload a picture of the front of your drivers license
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Driver License Picture upload (back)* This field is required. Please upload a picture of the back of your drivers license
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
Please upload a picture of your front hairline and the top of your head.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
How long ago did you first notice any sign of hair loss?* This field is required.
Within the last month or sooner
1-3 months
3-6 months
Over 6 months
Over 1 year
15
Which symptoms of hair loss have you had?* This field is required.(Check all that apply)
Dandruff
Gradual hair loss on top of head
Thinning on top of scalp
Thinning at the front hairline
Pain or burning scalp
Losing hair all over body
Red rings on scalp
Very itchy scalp
Other
16
Can you please elaborate on the symptoms of hair loss you have?* This field is required.
17
How do you feel emotionally?* This field is required.
Feeling fine emotionally
Having some issues emotionally
Feeling depressed, emotional, and poor self-esteem
Having suicidal thoughts and extreme depression
18
Have you had a physical in the last 6 months?* This field is required.
YESNO
19
Do any of the following currently apply to you?(check all that apply to you)
Mild dandruff
Scalp psoriasis
Severe dandruff
Scalp Eczema
20
Which treatments have you tried previously?(Check all that apply)
Minoxidil or Rogaine
Biotin or hair vitamins
Nioxin
Finasteride
Propecia
Saw Palmetto
Other
21
Can you please elaborate on the previous treatments you have tried? * This field is required.
22
Do you have a family history of hair loss or thinning hair?* This field is required.
Mothers side
Fathers side
No
Other
23
Please elaborate on family history of hair loss or thinning. * This field is required.
24
Have you had an abnormal pap smear?* This field is required.
YESNO
25
Do you have erectile dysfunction currently?* This field is required.
Yes
No
Other
26
Please elaborate about erectile dysfunction * This field is required.
27
Do you have any medical conditions?* This field is required.(We need to know any medical conditions minor and major to ensure the best quality care)
YESNO
28
Yes, please explain * This field is required.
Huge
Large
Normal
Small
Ok
Ok
29
Have you ever had any surgeries or hospitalizations?* This field is required.(Including cosmetic procedures)
YESNO
30
Yes, Explain (Date and Procedure)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
31
Do you have any medication allergies?* This field is required.
YESNO
32
Yes, please list your allergies.* This field is required.
33
Have you ever had any of the following medical conditions?(Check all that apply)
HIV
Kidney Problems
Problems Urinating
Breast Cancer
Lupus or Discoid Lupus
Prostate Cancer
Problems with Immune System
Prostate Enlargement
Fungal Infections
Thyroid Issues
High Blood Pressure
Autoimmune Disease
34
Any additional information that you feel is important for the physician to know about your health background?
Huge
Large
Normal
Small
Ok
Ok
35
Patient Release of Information

Please list anyone whom we may inform of your medical condition and diagnosis (including
appointment, treatment, payment, and health care concerns). If the name is not listed, we are legally unable to give out any information regardless of the relationship with the patient. If you wish to list additional people, you may do so under your signature. You may remove a person’s name from this list at any time by simply contacting our office.
36
Patient Release of Information Signature.* This field is required.
Clear
37
Patient Release of Information
Full Name
Please enter your phone
Address / City / Zip Code
38
Padgett Medical Center Terms & Conditions.* This field is required.
39
Padgett Medical Center Terms & Conditions Signature.* This field is required.
Clear
40
HIPAA Information Release & Disclosure Notice.* This field is required.
41
HIPAA Information Release & Disclosure Notice(Health Insurance Portability and Accountability Act) Signature.* This field is required.
Clear
42
Patient Rights and Responsibilities.* This field is required.
43
Patient Rights and Responsibilities Signature.* This field is required.
Clear
44
Informed Consent for Telehealth Services.* This field is required.
45
Informed Consent for Telehealth Services Signature.* This field is required.
Clear
46
Please verify that you are human* This field is required.
Should be Empty: