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Hair Transplant
FUE Hair Transplant
Sapphire FUE Hair Transplant
DHI Transplant
Beard Transplant
Eyebrow Transplant
Woman Hair Transplant
Before And After Hair Transplant
About Us
Contact
Blog
FAQ
Home
Hair Transplant
FUE Hair Transplant
Sapphire FUE Hair Transplant
DHI Transplant
Beard Transplant
Eyebrow Transplant
Woman Hair Transplant
Before And After Hair Transplant
About Us
Contact
Blog
FAQ
Medical History Form
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Medical History Form
Medical History
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Please enable JavaScript in your browser to complete this form.
Date
*
Name
*
First
Last
Treatment Type
Age
*
Height
*
Weight
*
List of medications you are currently using (including over-the-counter medications)
*
List of surgeries you have performed before (including plastic surgeries)
*
Date of Intervention
*
Surgical Intervention
*
Use herbal supplements or vitamins (especially Gingko, ginger, garlic, St. John’s Wort, C, E, fish oil)?
*
Medicines that cause allergies
*
Are you a smoker?
*
Yes
No
If yes; For how long?
Are you an alcohol user?
*
Yes
No
If yes; For how long?
Do you have any of the following symptoms?
Chest pain
*
Yes
No
Breast diseases
*
Yes
No
Seizure
*
Yes
No
Heart problems
*
Yes
No
Thyroid problems
*
Yes
No
Tooth problems
*
Yes
No
High blood pressure
*
Yes
No
Hepatitis C
*
Yes
No
Emotional problems
*
Yes
No
Diabetes
*
Yes
No
Kidney problems
*
Yes
No
HIV
*
Yes
No
Cancer
*
Yes
No
Asthma
*
Yes
No
Eye problems
*
Yes
No
Problems with bleeding
*
Yes
No
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