Patients File

Edit Patient File

Patient Details

Name :

Treatment No :

Civil ID Number :

Nationality :

Sex :

Age :

Phone :

Emergency Phone :

Blood Group :

Hair Types:

Duration:

Total No. of Hairs:

Date and Time:

Treatment Type

Date First:

Hair Grafts:

Technician

Date Second:

Hair Grafts:

Technician

Date Third:

Hair Grafts:

Technician

Date Fourth:

Hair Grafts:

Technician

Date Retouch:

Hair Grafts:

Technician

Patient Category :

Hair Density:

History of Heart or Skin Type:

Blood Test:

Disease you have, had or are being treated

Eczema Psoriasis Alopecia Areata Blood Pressure Diabetes Pre Hair Transplant

Cost:

Discount:

Rhinoplasty:

Head Hair Treatment Eyebrows Treatment Beard Treatment Scars Treatment Mustache Treatment PRP Plasma Meso

Others:

Creation Date:

Last Updated on:

Date & Time	Notes	Created By

Treatment Notes:

Date	Notes

Are you currently receiving medical treatment or medical care of any kind?

Have you ever suffered, or do you now suffer from:

a. Epilepsy, fits or fainting attacks or other mental disturbances

b. Tuberculosis, asthma, persistent cough, Pneumonia or any other chest disease

c. Rheumatic fever, Hypertension, Circulatory or Heart trouble?

d. Indigestion, Chronic or recurrent diarrhea, gastric or duodenal ulcer, jaundice, gall bladder complain?

e. Diabetes mellitus, Cancer or tumor of any kind

f. Unexplained recurrent or persistent fever?

g. Unexplained persistent night sweats?

h. Unexplained weight loss

Current Weight (in kg) Height (in M)

i. Skin disorders

j. Nervous disease or nervous breakdown frequent headaches?

k. Hepatitis (B) or any sexual transmitted disease (e. Syphilis, gonorrhea) ?

Have you received or do you expect to receive any x-rays, electro-cardiogram or any other Hospital or pathological investigation and/or treatment?

Have you any physical defect or infirmity or is there any aliment or disease from which you suffered or to which you have a tendency other than stated above?

Are there any other circumstances such as engaging in dangerous sports or particular aspects of your occupation, which could be considered hazardous?

Are you a smoker?

Please state how many cigrettes you smoke a day if yes?

For Women only: Are you currently pregnant:

Did you undergo any dental treatment?

If yes, please specify:

Do you have any additional medical information?

Name list of two persons you know to contact

Name	Relation	Tel

Name	Check	Description