Hair Transplant History Questionnaire

 

The History of Hair Loss
and Hair Restoration
 
     Hair Loss  History Questionnaire Form
I would like to schedule a consultation with Dr. Epstein.Please contact me...
or, I will print, fill out and mail the Hair Loss History Questionnaire for Men or for Women.
Please send me a brochure
Please send me specific information on Cost (please see Cost... Priceless!)
 
First Name 
Last Name 
Address 
City 
State 
Zip Code 
Daytime Phone 
Preferred Email Address 
Privacy is necessary: 
Yes   No
     
Age 
Age at onset of hair loss 
How fast does hair loss 
currently seem to be progressing? 

Medications taken for hair loss (please give dates and effectiveness):
 
Rogaine (minoxidil) 2% 
Rogaine (minoxidil) 5% 
Minoxidil plus Retin-A 
Propecia (finasteride) 1mg 
Proscar (finasteride) 5mg 
Other 
 
 
Check Which Members of Family Have/Had Significant Hair Loss:
 
Father Mother Brother(s)
Paternal Uncle Maternal Uncle    
Paternal Grandfather Maternal Grandfather    
  Other 
 
 
Indicate Your Current Hair Condition:
 
Hairline Normal thinning Very Thin Bald
Frontal Recession Normal thinning Very Thin Bald
Frontal Area Normal thinning Very Thin Bald
Mid Scalp Normal thinning Very Thin Bald
Crown / Back Normal thinning Very Thin Bald



Using the following diagrams, Indicate Your Current Hair Loss Pattern
and the Hair Loss Pattern You Believe You May Progress To in the Future :

Men, please complete this first Hair Loss Pattern Chart. Women, please complete the one below.
 
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
Women, please complete the following Hair Loss Pattern Chart. The Men's chart is above.
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
  Current Pattern May Progress To
 
 
Indicate All the Characteristics of Your Hair:
 
Hair Color Black Brown Gray Blonde
  Red Salt & Pepper
Hair Curl Straight Slightly Wavy Wavy Curly
Hair Thickness Fine Medium Medium Coarse Coarse
 
Past Hair Surgery History (dates, physician/clinic, graft number):
 
Please Describe Your Goals for Hair Restoration:
 
 
Which of the Following Would Be Most Helpful to You (Indicate All that Apply):
 
In-Depth Consult Talking to Patients
Meeting Patients Viewing a Procedure