Your Hair Loss Evaluation
Absolute Hair Clinic

1. Age year Male Female
2. Your natural hair colour is? Black/Dark Brown
Grey
Medium Brown
Light Brown/Blond/Red
3. What is the texture of your hair? Straight
Wavy
Curly
4. What is the caliber of your hair at the back and side of your scalp (donor)? Fine
Medium
Thick
5. Choose the image that best describes your hair loss
 


Hair Loss Type II


Hair Loss Type IV


Hair Loss Type IIa


Hair Loss Type IVa


Hair Loss Type III


Hair Loss Type V


Hair Loss Type IIIa


Hair Loss Type Va


Hair Loss Type III vertex


Hair Loss Type VI

6. How long has your hair loss begun?
7. What are your expectations from hair transplantation? restore the front hairline
restore mid scalp
restore back
restore entire balding area
8. Have you had a hair transplant procedure? No
Yes
How many sessions
Date(s) of procedure
Number of grafts
Which clinic (whom)
9. Have you used any of these oral & topical medications for your hair loss?
Rogaine (minoxidil) Past
Present
How long?
Propecia (finasteride)
Past
Present
How long?
Other
  Past
Present
How long?
10. Has your family suffered a significant amount of hair loss?**  
  Grandfather(both sides) Yes No
  Grandmother(both sides) Yes No
  Father Yes No
  Mother Yes No
  Brother(s) Yes No
  Medical Illness
  Past Surgery
  Current Medications
  Allergy Yes No
  Smoking Yes No
  Drinking Yes No

Your Hair Loss Evaluation

Note: This form and any reply to it do not take the place of an actual in person consultation. It is merely intended to provide us with an initial idea of your condition and goals. With this information we can then give you an informed reply.
First Name:
Last Name:
Email:
Country:

Guidelines for attached photos
To provide the most accurate assessment and give you an estimated number of graft, please use the following hair transplant photo guidelines:
  • Let somebody shoot it for you
  • Avoid using flash, use adequate bright fluorescent room lighting.
  • Clear background without distraction
  • Make sure that the area you are shooting is in frame and in focus
  • Please resize photos that exceed 1 Mb per each.
  • Acceptable photo file types are jpg or jpeg.
Provide photos showing the following positions:
Lower Face

Lower Face

1 Mb Max (.gif, .jpg Only)

Top view

Top view

1 Mb Max (.gif, .jpg Only)

The back of the head (donor area)

The back of the head (donor area)

1 Mb Max (.gif, .jpg Only)

Left profile

Left profile

1 Mb Max (.gif, .jpg Only)

Right profile

Right profile

1 Mb Max (.gif, .jpg Only)


Your Message
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Gallery
Before -  After  Strip FUT
Before -  After  doing eyebrow transplant
Before -  After doing mustache transplant
Before -  After  doing hair transplant
Before -  After  doing eyebrow transplant


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