Hair Transplant Suitability Questionaire

Norwood Hair Loss Scale

First Name

Surname

Gender

DOB

Age

How long have you been experiencing hair loss?

At what age did you first notice hair loss?

What areas of the scalp are affected by hair loss?

Look at the Norwood Hairloss scale above. Please tell us where you sit on the Norwood scale?

Which area of hairloss is most important to you, the front or the crown area?

Have you noticed a recent progression in your hair loss recently?

Do you have a family history of hair loss?

At what age did your family members start experiencing hair loss?

How severe was your family members balding?

Do you have any scalp conditions that you know of? Please specify

Have you noticed you hair becoming finer and thinner?

Is your hair greying?

Is your hair curly? Please specify

Do you have any wrinkles or skin folds in the back of your head?

Do you have any existing medical conditions? Please specify

Are you currently taking any medications? Please specify

Do you have any allergies , particularly to medications and anaesthesia? Please specify.

Do you have any latex alergy?

Are you currenly taking any medications for hair loss? Please specify

Have you had a hair transplant in the past?

Do you smoke?

How often do you consume alcohol?

Do you follow a particular diet or have any dietary restrictions? Please specify

Do you have any bleeding disorders?

Do you have high blood pressure?

Do you have any phobias of blood or needles?

What are you main reasons for considering a hair transplant?

What are your expectations from a hair transplant procedure?

How important is hair resoration an a scale of 1-10?

Are you willing to follow post procedure care instructions?

Would you like to receive more information or schedule a consult?

How familiar are you with the hair transplant process?

Do you have any questions or concerns about hair transplant?

Can you please upload some photos of your hair from the front and back. You may hide your identity if you wish.

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Thank you for completing the Hair Transplant Suitability questionaire. A member of out team will contact you in the near future by email.

Hair Transplant Suitability Questionaire

Norwood Hair Loss Scale

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