Medical History Form In order to request your Virtual Consultation with Dr. Boden please complete the medical history form below. Please call (860) 563-1400 with any questions. InstagramThis field is for validation purposes and should be left unchanged.Name* First Last Cell Phone*Email* Date of Birth* MM slash DD slash YYYY Age*Please enter a number from 18 to 90.Is your scalp tender where you have hair loss?* Yes No How fast are you losing your hair at this time?* Stable Slow Fast Which family members have hair loss?* Father Mother Sibling Extended Relative None Are you allergic to any medications?* Yes No Have you ever been treated for any of the following? (Check all that apply) Respiratory problems, including asthma, shortness of breath or chronic lung disease Cardiovascular problems, including chest pain, high blood pressure, heart attack, angina, heart valve problems, or stroke. Any dermatologic problems, including eczema, psoriasis, dandruff, or chronic rash Any type of cancer, including skin cancer Any metabolic problem such as thyroid disease or diabetes Any bleeding problems such as nosebleeds, easy bruising or anemia Any mental health concern such as depression, anxiety or panic disorder Any immune system disorder Please list any diseases that you have had or are being treated for that are not listed:Do you take any blood thinners (Aspirin, Ibuprofen, Coumadin, Plavix, Fish Oil, etc)?* Yes No If yes to blood thinners, please list below:Do you have any allergies?* Yes No If yes please list your allergies below:Do you require preventative antibiotics prior to dental procedures or have you had joint replacement or heart valve replacement?* Yes No If yes to requiring preventative antibiotics please list below:Please list ALL prescription/non-prescription/herbal meds or supplements that you are currently taking:Please list all previous surgeries, including hair restoration procedures:Weekly alcohol intake?Weekly cigar/cigarette use?Females only: Date of your last menstrual period? MM slash DD slash YYYY Are you pregnant? Yes No May we communicate with your health care provider(s) to review any medical concerns? Yes No Consent* I acknowledge that HIPPA Privacy Practices have been made available to me and I understand that all medical information will be kept confidentialPlease enter full name.*Date* MM slash DD slash YYYY Δ
