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DERMATLANTA.COM > GRIFFIN CENTER OF HAIR RESTORATION AND RESEARCH > PATIENT QUESTIONNAIRE

Patient Questionnaire

If you're considering a hair replacement procedure, please print this form, complete it, and mail it to The Griffin Center, 5555 Peachtree Dunwoody Road, Suite 190, Atlanta, GA 30342. Or, you may fax the form to us at 404-843-3469 or you may complete it and e-mail it directly to us online. Be aware that the security and confidentiality of information over the internet cannot be guaranteed. Our patient base extends to many parts of the country and a member of our staff would be happy to speak with you personally about your goals and desires.

Please tell us more about you. This medical information is intended as an informational service for internal purposes only.

Name:
E-mail:
Date:
Address:
Phone Number:
Age:
Best time of day to contact you:
Have you ever been treated for hair loss?
If so, by whom and when:
Family history of hair loss:
List all past surgeries:
Do you have any medical problems?
Do you have any health diseases?
How does hair loss affect your life?
What specifically would you like to learn?
How long have you been experiencing hair loss?
Have you had above average hair loss recently?
Current treatments used:
Do you eat a daily balanced diet?
Are you currently on a diet?
If yes, how long?
Have you had any weight loss?
If yes, how many pounds?
What medications are you currently taking, including hormones?
List vitamins you are currently taking:
Has your stress level increased?
Have you suffered any type of recent illness?
Have you had any significant events recently occur such as divorce, death in the family, or family illness?
Have you been sick with a fever recently?
Have you been exposed to any type of chemicals such as pesticides or radiation?
If so, what and when?
When was your last physical?
Doctor's name:
Were the results normal?
Any known allergies to medications?
Type of shampoo and conditioner used:
Do you have hair permanents or hair coloring?
If yes, how often?
FEMALES ONLY
Have you given birth within the past three to six months?
Did you have any complications?
Thank you. We look forward to speaking with you and meeting you in the future.

DERMATLANTA.COM > GRIFFIN CENTER OF HAIR RESTORATION AND RESEARCH > PATIENT QUESTIONNAIRE

Patient Questionnaire

Name:

E-mail:

Date:

Address:

Phone Number:

Age:

Best time of day to contact you:

Have you ever been treated for hair loss?

If so, by whom and when:

Family history of hair loss:

List all past surgeries:

Do you have any medical problems?

Do you have any health diseases?

How does hair loss affect your life?

What specifically would you like to learn?

How long have you been experiencing hair loss?

Have you had above average hair loss recently?

Current treatments used:

Do you eat a daily balanced diet?

Are you currently on a diet?

If yes, how long?

Have you had any weight loss?

If yes, how many pounds?

What medications are you currently taking, including hormones?

List vitamins you are currently taking:

Has your stress level increased?

Have you suffered any type of recent illness?

Have you had any significant events recently occur such as divorce, death in the family, or family illness?

Have you been sick with a fever recently?

Have you been exposed to any type of chemicals such as pesticides or radiation?

If so, what and when?

When was your last physical?

Doctor's name:

Were the results normal?

Any known allergies to medications?

Type of shampoo and conditioner used:

Do you have hair permanents or hair coloring?

If yes, how often?

FEMALES ONLY

Have you given birth within the past three to six months?

Did you have any complications?

Thank you. We look forward to speaking with you and meeting you in the future.