HAIRLOSS CONSULTATION QUESTIONNAIRE

PERSONAL DETAILS









GENDER

MaleFemaleOther

DATE OF BIRTH


HAIRLOSS DETAILS







HEALTH QUESTIONNAIRE



Have you ever been refused as a blood donor or had problems donating blood?YesNo
Have you ever had a serious illness; cancer, diabetes, heart or lung disease (including heart surgery and/or stroke), convulsions, chest pains, asthma, Mitral valve prolapse or shortness of breath?YesNo
Have you ever had neck, back, hip or spine problems? does your condition require treatment?YesNo
Have you ever had hepatitis, yellow jaundice, liver disease or a positive blood test for hepatitis? YesNo
Have you ever tested positive for HIV antibodies (the AIDS virus)? YesNo
Have you ever been treated for abnormal bleeding? YesNo
In the past month, have you taken any drugs prescribed by a physician? YesNo
Have you ever had an operation besides a hair transplant? YesNo
Have you or are you receiving treatment for any mental health problems or medical condition not disclosed? YesNo
Have you ever had an operation besides a hair transplant? YesNo


Photos



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