Medical History Information

Patient Medical History Form

Please complete this form prior to your treatment. Your privacy is important to us, all information is strictly confidential and will not be shared, sold or transferred.

Name*

Address*

Address Line 2

City*

State*

Zip Code*

Date of Birth*

Age

Marital Status*

Phone*

Phone (Secondary)

Occupation

How did you hear about National Hair Centers?

Email*

Best way to contact you:

Do you have any allergies to food or medicine?

Yes

No

If so, please list:

Do you currently use any prophylactic antibiotics?

Yes

No

Which one(s)?

Are you currently taking any medications?

Yes

No

Please list:

Are you taking any vitamins or herbal supplements?

Yes

No

Please list any vitamins or supplements:

Are you taking any over the counter medications?

Yes

No

Which medications?

Do you drink alcohol?

Yes

No

How much and how often?

Do you currently use IV drugs?

Yes

No

Which kind and in what frequency?

Have you ever had a blood transfusion?

Yes

No

Have you ever been exposed to HIV/AIDS?

Yes

No

Are you allergic to latex?

Yes

No

Do cuts on your skin heal with normal scars?

Yes

No

Please list any other disease or condition we should be aware of:

Please list any surgeries you've had, including cosmetic procedures:

Do you smoke?

Yes

No

Do you bleed easily?

Yes

No

Do you have artificial joints, pins or screws?

Yes

No

Do you require antibiotics prior to surgery?

Yes

No

Are you pregnant?

Yes

No

N/A

Have you had a hysterectomy?

Yes

No

N/A

Have you experienced menopause?

Yes

No

N/A

Pharmacy Name

Pharmacy Phone:

I hereby authorize consent to submit this form to National Hair Centers prior to my treatment. Please sign your FULL NAME below:*