PATIENT INFORMATION
Patient Information
First Name
Last Name
Age
D.O.B
Mailing Address
City
State
Zip Code
Cell Phone
Email
Occupation
How did you hear about DiStefano Hair Restoration Center?
Primary Care Physician & Emergency Contact
Primary Care Physician Name:
Address Of Primary Care Physician:
City
State
Zip Code:
Primary Care Physician Phone:
Emergency Contact Name:
Relationship to Patient:
Emergency Contact Phone:
Patient Communication Consent Form
I authorize the physician at DiStefano Hair Restoration Center and his medical staff to leave messages for me when I am unavailable.
I authorize the physician at DiStefano Hair Restoration Center to discuss my healthcare information (which may include history, diagnosis, labs, test results, treatment and other health information) with any of my personal physicians, if required.
MEDICAL HISTORY FORM
DO YOU HAVE A HISTORY OF: (Please circle specific disease and “Y” or “N”)
Bleeding problems (anemia, nose bleeds, gum bleeds, easy bruising, etc.)
Yes
No
Poor or abnormal healing (wide scars, raised scars, larger scars, keloids, slow healing)
Yes
No
Liver problems (hepatitis, fatty liver disease, etc.)
Yes
No
High blood pressure
Yes
No
Heart disease (heart attack, arrhythmia, irregular pulse, heart murmur, etc.)
Yes
No
Lung disease (asthma, pneumonia, chronic bronchitis, etc.)
Yes
No
Endocrine disease (diabetes, thyroid dysfunction, etc.)
Yes
No
Stomach disease (ulcers, heartburn, etc.)
Yes
No
Neurological disease (stroke, seizures, epilepsy dizziness, fainting, frequent headaches, etc.)
Yes
No
Dermatological problems (hives, eczema, psoriasis, alopecia areata, etc.)
Yes
No
Artificial joints, heart valves or metal pins
Yes
No
Disorders of the Immune System (lupus, etc.)
Yes
No
Blood Transfusions
Yes
No
Psychiatric disorders (depression, anxiety, panic disorder, etc.)
Yes
No
Have you ever been told you need antibiotics PRIOR to surgery?
Yes
No
Rare disorders (hereditary angioedema, malignant hyperthermia, etc.)
Yes
No
Are you allergic to or have had a “bad reaction” to any of the following local anesthetics and other medications that are occasionally used in hair restoration surgery: (Please select below items)
Novocaine
Xylocaine
Skin Tape
Iodine
Valium
Versed
Prednisone
Penicillin
Sulfa Antibiotics
Codeine
Please list any other medications to which you are allergic or have had a “bad reaction” to:
List all prescription and/or non-prescription medications, drugs, vitamins, or nutritional supplements you take either regularly or occasionally: (including Rogaine, Vitamin, E, over-the-counter pain medications such as Advil, Motrin, Ibuprofen, Tylenol, etc.):
Please list any operations or serious medical illnesses not mentioned above or give details of questions answered “Yes”:
Hidden
Male Hair Evaluation Form
Hair Loss History
At what age did you first notice hair loss?
How fast are you losing hair at this time?
Stable
Gradually
Quickly
Which family member(s) also have hair loss?
Who has the worst hair loss in your family?
Do you resemble this family member’s pattern of hair loss?
Yes
No
Have you ever had a prior hair restoration surgery? If so, please list the date(s), number of grafts, and who performed the procedure.
Where is your hair loss most bothersome?
Receding in the front
Thinning in the crown
Thinning everywhere
What concerns you most about your hair loss?
Are you on Propecia (Finasteride)? (If yes, when did you begin?):
Are you on Rogaine (Minoxidil)? (If yes, when did you begin?):
What other products or treatments have you used to try to improve your hair?
What concerns, if any, do you have in relation to restoring your hair?
What are your goals and expectations (Please describe what you would like to accomplish with hair restoration surgery)?
Female Hair Evaluation Form
(NOTE: If you are a MALE please skip to the bottom of the page and press "Submit".
1. Do you have a history of low iron?
Yes
No
If so, are you taking supplementation?
2. Have you had a serious illness during the past year?
Yes
No
If yes, approximately how long ago?
3. Have you been hospitalized during the past year?
Yes
No
If yes, when were you hospitalized?
4. Have you been under a severe amount of stress over the past six months?
Yes
No
5. Have you started any special diets during the past year?
Yes
No
If so, which type of diet are you currently on?
6. Have you ever had excessive shedding?
Yes
No
If so, for how long?
7. Are there any types of medications that you were taking when you noticed your hair falling out?
Yes
No
If so, please list the medication(s) below:
8. Do you take any supplements or vitamins?
Yes
No
If so, please list:
9. Do you get your menstrual period each month?
Yes
No
If yes, how often does your period come?
10. Have you been pregnant during the past year?
Yes
No
If yes, when did the pregnancy end?
11. Have you ever taken hormones or oral contraceptives?
Yes
No
If yes, please list
12. Have you ever had issues with fertility?
Yes
No
13. Do you have unwanted or excessive hair growth anywhere on the body?
Yes
No
If so, where is it located?
14. Have your hormones ever been checked to evaluate your hair loss problem?
Yes
No
If yes, when?
What was the result?
15. Does your scalp itch or sometimes burn or hurt?
Yes
No
16. Have you gained or lost any weight recently?
Yes
No
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