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PRP Suitability Questionaire
Norwood Hair Loss Scale
First Name
Surname
Gender
Male
Female
DOB
Age
Email
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?
Front
Top
Crown
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?
Yes
No
Do you have a family history of hair loss?
No
Father
Mother
Siblings
At what age did your family members start experiencing hair loss?
How severe was your family members balding?
N/A
Front only
Top Only
Front and top
Very bald
Do you have any scalp conditions that you know of? Please specify
Have you noticed you hair becoming finer and thinner?
Yes
No
Have you had a hair transplant in the past?
Do you have any existing medical conditions? Please specify
How would you describe your overall health?
Excellent
Good
Fair
Poor
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?
yes
no
Are you currenly taking any medications for hair loss? Please specify
Do you smoke?
Yes
No
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?
Yes
No
Do you have high blood pressure?
Yes
No
Do you have any phobias of blood or needles?
yes
no
How important is hair resoration an a scale of 1-10?
Do you have any specific concerns or fears about undergoing PRP therapy?
yes
no
Do you have any chronic illnesses or autoimmune diseases that might affect healing or the effectiveness of PRP therapy?
no
yes
Are you aware that PRP is most successful in the early stages of hair loss?
yes
no
Are you aware of other treatment options for hair loss such as medical treatment, Regenera Activa, skin needling with NTCF or Exosome Therapy?
yes
no
Are you ready to commit to a treatment plan that may include follow-up sessions and maintenance?
no
yes
Would you like to receive more information or schedule a consult?
Yes
No
Can you please upload some photos of your hair from the front and back. You may hide your identity if you wish.
Send
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