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Personal Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Email
Gender
- Male
- Female
- Binay
Date of Birth
MM slash DD slash YYYY
How Did You Hear About Us?
Who can we thank?
If Word of Mouth Referral, who can we thank?
What Form of Treatment Are You Most Interested In At This Time? (Can choose more that one)
- Surgical FUT
- Surgical FUE
- Scalp Micro-Pigmentation
- Medical Treatment (Propecia, Rogaine, Laser, etc.,)
- Regenerative Medicine (PRP, Exosome, etc.,)
What would you find most useful? (Can choose more than one)
- In-Depth Consultation
- Talking/Meeting Former Patient
- Observing Surgery
Hair Loss History
Main Problem & Goals:
At what age did your hair loss begin?
How fast are you losing hair at this time?
Who has the worst hair loss in your family?
Does your loss resemble this family member?
What pattern on the below diagrams does this family member most closely resemble?
Are you on Propecia?
- Now
- Past
Are you on Rogaine?
- Now
- Past
Are you using Low Level Light Therapy (Laser)?
- Now
- Past
Have you used Scalp Mirco Pigmentation?
- Yes
- No
Have you used Regenerative Medicine?
- PRP
- Exosomes
- No
INSTRUCTIONS AND DIAGRAM TO ASSIST IN CHOOSING DEGREE OF THINNING BELOW

Normal: No visible hairloss or ability to see scalp under any condtions

Early thinning: Appears thin and able too see scalp under certain conditions such as bright lights, when wet etc.,

Late Thinning : Appears thin and able to see scalp under all conditions

Bald: Virtually no hair
Degree Of Thinning In Each Recipient:(Please Circle And ReferTo Diagram ):
Hairline
Frontal Core
Bridge
Crown
Hair Characteristics
Hair Curl:
Hair Thickness:
Skin Color:
Hair Color:
Do you dye or color your hair?
- Yes
- No
Donor Characteristics
Donor Density:
Donor Laxity:
Head Size:
Past Hair Surgery History:
I have a past Hair Surgery
- Yes
- No
Details of past history, if you remember (dates/number of grafts/surgeon):
Medical History
Bleeding Problems
- Yes
- No
Poor or Abnormal Healing:
- Yes
- No
HIV or Hepatiis C Positinve
- Yes
- No
Liver Problems :
- Yes
- No
Diabetes :
- Yes
- No
High Blood Pressure :
- Yes
- No
Heart Disease (heart attack, arrhythmia, or irregular pulse, heart murmur, etc.):
- Yes
- No
Lung Disease (asthma, pneumonia, chronic bronchitis) :
- Yes
- No
Kidney / Bladder / Prostate Disease:
- Yes
- No
Stomach Disease (ulcers, heartburn, etc.) :
- Yes
- No
Neurologic Disease (stroke, seizure, fainting) :
- Yes
- No
Do you have any artificial joints, artificial heart valves, metal pins, etc. in the body?:
- Yes
- No
Emotional problems (depression, anxiety, panic disorder, etc.):
- Yes
- No
Have you been told you need antibiotics PRIOR to surgery ?*
- Yes
- No
Please explain in detail to answers of "yes" above :
Skin disorder ( poor healing, Folliculiis, skn infections*
- Yes
- No
Average Weekly Alcohol Intake:
Average Weekly Cigarette Use :
Are you allergic to any of the following medications which are occasionally used in surgery :
List any other medications to which you are allergic :
List all Over the Counter or Prescription medications :
Please list any operations, hospitalizations or medical illness not mentionedabove :

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Phone*

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ZIP / Postal Code

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5270 W. 84th St., Suite 500, Minneapolis, MN 55437

Disclaimer: Not all photographs on this website contain actual patients of Shapiro Medical Group and are for illustrative purposes only.

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Home
About
Procedures
- All Procedures
- FUE
- FUT
- SMP
- PRP / ACELL
- Medical Therapy
Results Galleries
- Photo Gallery
- Video Gallery
Learning Center
Patient Resources
Blog
Contact

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