Hair Transplant History Questionnaire

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Consultation

	I would like to schedule a consultation with Dr. Epstein or another Foundation for Hair Restoration™ doctor. 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!)
	Request a WebCam Consultation

How you would like
to setup a consultation?

(Required)

First Name

(Required)

Last Name

(Required)

Address

City

(Required)

State

(Required)

Zip Code

Country

(Required)

Daytime Phone

Preferred Email Address

(Required)

Referred By

Privacy is necessary:

Yes

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

Frontal:

Top:

Side:

Back:

Virtual Consultation

For patients who are unable to attend an in-office consultation, we provide a virtual consultation at no cost. Simply fill out the virtual consultation form and submit photographs showing your current state of hair loss.

Guidelines for Photographs

Please follow the guidelines listed below when submitting your photographs. This will allow your virtual consultation to be as close as possible to an in-person consultation.

When taking your photographs:

Do not use a flash. Instead, take the photographs in a room with bright, natural lighting.
Have the photographs taken from a distance of three to five feet.
Keep the target in focus and centered in the frame.

When submitting your photographs:

Use digital photos or print photos that have been scanned.
Use jpg or jpeg file types.
Do not exceed 4MB (4,000kb) per photograph. Larger photographs must be resized.
If your photographs exceed the size limit, you may resize them by downloading PhotoResize800.exe (Windows only). After download, the PhotoResizer icon will appear on your desktop. You may then drag and drop specific photos or folders containing photos onto the icon. The PhotoResizer will then automatically resize the photos, creating smaller copies of them.

For your virtual consultation, we will require photographs showing the following angles:

The top of the head. A photograph showing the top of your head will provide us with an overall view of your current hair loss, including the degree of current hair loss as well as potential hair loss that may occur in the future.
Side profiles. Photographs showing the left and right sides, or profiles, also demonstrate the extent of hair loss.
The back of the head. Two photographs should be taken of the back of the head, or scalp. One should simply be a photograph of the back of the head. The other should be taken of the back of the scalp while you are pulling up a horizontal strip of hair in the donor area using your hand or a comb. This second photograph will help us to assess the density of donor hair.
Hairline. A photograph of the front hairline will allow use to see how your hairline frames your face. If you have an idea how you would like your hairline to look, you may demonstrate this by drawing your hairline on your scalp.