Medical History Form | TJ Hair Clinic

Name *

Email Address *

Phone

Sex *

Age *

Height (ft)

Where are you contacting us from?

Address

Country

City

State

Zip / Post Code

What type of hair transplant are you interested in?

FUE Transplant

FUE Transplant
Others

Have you had any medical issues in the following areas? If so, please explain them below:

Digestive (Chronic heartburn/GERD, IBD, IBS):

Yes
No

Explain your digestive issue

Renal (Chronic kidney disease, kidney stones, glomerulonephritis)

Yes
No

Explain your Renal Issue

Endocrine (Osteoporosis, thyroid, diabetes)

Yes
No

Explain your Endocrine Issue

Neurologic (Alzheimer's disease AD, epilepsy, multiple sclerosis, migraines)

Yes
No

Explain your Neurologic Issue

Allergies (pollen, dust, specific medications, aspirin)

Yes
No

Explain your Allergies

Blood Transfusion

Yes
No

Explain your Blood Transfusion Issues

Other

Have you had any other type of surgery before?

Yes
No

please tell us what type of surgery and what year

Do you exercise?

Yes
No

how often?

Do you drink alcohol?

Yes
No

how often?

Do currently take medications?

Yes
No

please tell us what medications

Do you take drugs?

Yes
No

Have you had immunizations?

Yes
No

Can you please explain if you have any current diagnosis or other medical problem?

Is there anything else you would like to explain to the doctor before your consultation?

Please upload a couple of pictures of the problem areas for evaluation

Submit

<# let myType = data.type if('save'== data.type){ myType = 'button' } #>