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  • Hair Loss History


  • INSTRUCTIONS AND DIAGRAM TO ASSIST IN CHOOSING
    DEGREE OF THINNING BELOW

    Normal: No visible hair loss or ability to see scalp under any conditions

    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

    DIAGRAM



  • Degree Of Thinning In Each Recipient:(Please Circle And Refer To Diagram ):


  • Hair Characteristics


  • Donor Characteristics


  • Past Hair Surgery History :