Medical Questionnaire -

Patient Information & History:

Patient Intake Form (#3)

First Name

Last Name

Contact Number

Dateof Birth

Address

Email Address

Have you ever had any medical conditions (e.g., diabetes, heart disease, blood disorders, etc.)? If yes, please specify and provide details of treatment.

List all medications, supplements, and vitamins you are currently taking, including dosage.

Have you ever had any allergic reactions to medications, anesthesia, or latex?

Do you have any known allergies to local anesthetics?

Have you ever had a previous hair transplant procedure? If yes, please provide details.

Have you had any major surgeries or hospitalizations in the past? If yes, please specify.

Do you smoke or use tobacco products? If yes, please specify the frequency and quantity.

Do you consume alcohol regularly? If yes, please specify the frequency and quantity.

Have you ever used recreational drugs or substances? If yes, please specify the type and frequency.

Do you have a history of psychological or psychiatric conditions, including anxiety or depression?

Have you ever been diagnosed with a bleeding disorder or are you taking blood-thinning medications (e.g., aspirin, warfarin, etc.)?

Are you currently pregnant or planning to become pregnant in the near future (for female patients)?

Have you ever been diagnosed with hepatitis, HIV, or any other infectious diseases?

Do you have any existing skin conditions or scalp disorders (e.g., psoriasis, eczema, etc.)?

Are you currently undergoing any other medical treatments or therapies? If yes, please specify.

Patient Information & History:

Quick Links

Get in Touch