Medical History Form
Email address *
Full Name *
Age
Birth Sex
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Civil Status
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Contact Numbers
How did you find out about us? *
Occupation
Occasionally the Asian Hair Restoration Center have items of interest such as new techniques or medications. Would you like to have notices such as these sent to your home or email address?
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How long have you been having Hair Loss?
Are you using any medications for hairloss?
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If yes, please list medications used for hairloss
Is your Father Bald? If yes, please select from the picture the baldness pattern *
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Is anyone in your mother's family bald? If yes, please select from the picture the baldness pattern *
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Is any of your siblings bald? If yes, please select from the picture the baldness pattern *
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Are you bald? If yes, please select from the picture the baldness pattern *
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Have you ever had any of the Following?
Yes
No
Reactions or allergies to local anesthetics such as those used by a dentist?
Fainting of Fainting spells?
Do cuts in your wounds heal with normal Scars?
Do you require more "freezing or numbing" at your dentist?
Bad reactions to any substances applied to your skin
Bad reactions to Librium, Valium, steroids, antibiotics, or stitches?
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Have you ever had any previous Cosmetic Surgery? if yes please list down.
Date of last Executive Checkup?
MM
/
DD
/
YYYY
Last PSA Value
Do you have a History of: *
Yes
No
Bleeding Problems (nose bleeds, gum bleeds, easy bruising, anemia )
Poor or abnormal healing ( wide scars, raised scars, large scars, keloids, slow healing)
Ophthalmologic (Eye Problems, cataract, glaucoma) Y N
Ear Problems (Ear aches, abnormal discharge, decrease hearing)
Liver Problems (hepatitis A, B, C)
High Blood pressure
Heart Disease ( heart attack, chest pain, arrhythmia, irregular pulse, murmur, rheumatic fever)
Lung Disease (asthma, pneumonia, chronic bronchitis, pleurisy)
Hormonal Disease ( diabetes, thyroid problems, etc.)
Kidney, Bladder disease, prostate problems
Stomach disease (ulcers, heart burn)
Neurologic Disease (Stroke, seizure, fainting, epilepsy, meningitis, neuralgia, migraine)
Hay fever, hives, eczema
Glaucoma
Do you have any artificial joints, valves, metal pins
Disorders of the immune system (arthritis, joint pains)
Tattoos
Blood Transfusions
Venereal/ Sexually Transmitted Diseases (HIV)
Emotional Problems (depression, anxiety, panic disorder, etc.)
Rare disorders (hereditary angioedema, Malignant hyperthermia)
Do you require more anesthetic solutions than most people?
Please list history of any other medical illness not mentioned above and include the treatment
Please list history of previous hospital admissions
Please check the medications you are currently on *
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List all prescription and non-prescription medications, vitamins and supplements that you are using which are not mentioned above
Do you have any Allergy to these medications? *
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Indicate the Names of the drugs above that you have allergies to
Weekly Alcohol intake
Weekly Cigarrete Use
Other drugs
Do you smoke?
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How many packs per day?
Have you tried to quit?
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Can you go an 8 hour period without smoking?
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How many packs did you smoke in a day?
If you have quit smoking, when did you quit? what did you use to help you quit smoking?
Pertinent Family History
What treatment interests you the most? *
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Other Comments and Suggestions
Do you consent to Teleconsultation? *
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I attest that all information given above is accurate and correct information *
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