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History:
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Past Medical History:
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Drug Allergies?
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Bleeding Tendencies?
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Past Surgical History?
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Pace Maker?
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History of Scarring, Keloid?
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Current Medications:
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Family History of Hair Loss?
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Hair loss treatment used?
• • •
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Vitamin/Supplements?
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Social History:
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Hair & Scalp Evaluation:
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Current Pattern:
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Anticipated Pattern:
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Density:
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Scalp thickness:
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Hair Color:
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Skin Color:
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Curl:
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Texture:
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Vellous Hair:
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Terminal Hair:
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Hair Caliber:
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Donor Area:
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Problems:
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Scalp Elasticity?
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Surface are of baldness?
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Locations?
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Locations (Other):
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Area of Baldness:
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Patient Stated Goal:
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Treatment Plan:
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Past Scalp Reduction:
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Previous transplant:
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Estimated Graft Sessions:
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Number of procedures required:
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Propecia Rx:
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Other medical tx:
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HIV and Hep B & C blood work:
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Procedure Explained:
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Areas most concern?
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Areas to be transplanted?
• • •
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Assessment:
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Plan:
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