Hair Loss New Patient Consultation Intake Form
Confidential Medical History and Aesthetic Interest Form
Today's Date
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Month
-
Day
Year
Date
Legal Name
*
First Name
Last Name
Preferred name (optional):
Date of birth
*
/
Month
/
Day
Year
Date
Gender
Female
Male
Other
Tel No:
*
email:
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you find out about us?
How did you hear about PRP in general for hair loss?
Medical History
How long have you been experiencing hair loss?
*
Less than 1 year
1 - 5 years
5 - 10 years
Over 10 years
Have you ever been diagnosed with any of the following hair disorders? (please check all that apply)
*
Alopecia Areata
Androgenic Alopecia
Female Pattern Hair Loss (FPHL)
Retrograde Alopecia
Traction Alopecia
Chemotherapy or other medication related hair loss
None of the above
Have you ever been diagnosed with any of the following medical conditions?
*
Anemia
Thyroid disorder
Vitamin D deficiency
Diabetes
Hepatitis or other liver disease
Bleeding or clotting disorder
Cancer
Herpes or cold sores
Low platelets (thrombocytopenia)
High cholesterol (dyslipidemia)
Please indicate any other concerns you wish to discuss:
Medication and Allergies
Do you have ANY allergies to medications, food, latex, or other substances?
*
Have you tried any of the following medications or treatments for hair loss?
Minoxidil / Rogaine
Propecia or finasteride
Biotin
Vitamin D
Hair Transplant
Laser treatment
Microneedling
Previous PRP, Acell, Exosomes or other regenerative therapy
Please list ANY medication, herbal/ natural supplements or topical creams which you uon a regular basis?
Have you ever had history of the following?
*
Yes
No
Unsure
Skin Disorder
Autoimmune Disease (Lupus, other)
Keloid scarring
Herpes or Cold Sores
Bleeding or clotting disorder
Active Infection
Hepatitis B or Hepatitis C
H.I.V.
Myasthenia Gravis, Amyotrophic Lateral Sclerosis any other Neuromuscular disorders
If yes or maybe to any of the above, please provide details:
Certification
I certify that I have answered all questions to truthfully to the best of my knowledge and will advise my treatment provider if there are any changes to my health history in the future.
Patient Signature
*
Clear
Please print your name
*
Please verify that you are human
*
Submit
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