Health History Form

Health History Form

Health history

Patient Information

Gender
In case of Emergency
Preferred Pharmacy
Health History
Family history of hair loss
Your history of hair loss
Are you still currently shedding hair?
Current/past treatment and length of use
Minoxidil
Finasteride
Laser
Supplements
Scalp treatments
Previous Hair Transplant
Other
Current medications
Hormone Replacement Therapy
Testosterone
Allergies
Do you have/have you ever been treated or evaluated for the following: Please answer Yes or No
Hypertension (high blood pressure)
Diabetes (including family history)
Liver Disorder (including hepatitis)
Wound Healing or Scarring Problems
Head Trauma or Brain Surgery
Bleeding Disorder (including family history)
Heart Disease
Asthma
HIV/Aids
Scalp Disease/Biopsy
Thyroid Problems
History of Irregular Periods
Sleep Apnea
Depression
Bipolar Disorder
Mood Disorder
Other
Lifestyle; do you currently/have you ever
Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.
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