CURRENT STATE OF HEALTH

Do you have any diseases?YesNo
If your answer is affirmative, indicate the type of medication administered

What disease / allergy do you have?

INFORMATION ABOUT HAIR LOSS

When did hair loss begin? DaysMonthsYears

How has hair loss happened? AbruptSlow and progressive
What treatments have you used to stop baldness? Hair massagesMinoxidiFinasterideShampoo for Hair LossOthers

Do you have a family history of baldness? MaternalPaternal
Have you previously consulted a specialist to treat baldness? YesNo
Have you ever consulted a hair transplant clinic? YesNo
Have you undergone a hair transplant before? YesNo
How long has it been since the last hair transplant?