WELCOME TO YOUR RESTORATION CONSULTATION WITH NORTH VALLEY PLASTIC SURGERY

Name: ______

What is your current concern?

Starting to thin Increased shedding

Advanced stage of thinning Missing, damaged or sparse

Overall thinning Weak or sparse

Receding hairline Damaged or traumatized eyelashes

Bald spot forming in crown Post-Plastic Surgery Hair Loss

Little or no hair on top of the scalp Visible Scar

Itching or flaking scalp

Please check the box which most closely matches your hair loss pattern.

Norwood 2 Norwood 2a Norwood 3 Norwood 3a Norwood 3 Vertex

Norwood 4 Norwood 4a Norwood 5 Norwood 5a Norwood 6

Ludwig 1 Ludwig 2 Ludwig 3

O Other ______

If you camouflage your thinning/balding hair, which methods have you used?

Wig, toupee or weave Hair extensions Creative hair styling (comb-over, perms) Powder or spray camouflage

What is your family's history of hair loss?

Mother

Father

Maternal grandparents

Paternal grandparents

Brother/sister

Don't know

Your personal hair restoration objectives (check all that apply):

Hairline restoration

Increase in frontal density

Crown coverage

Stop hair loss / decrease shedding

Touch-up, refinement or correction of previous procedure

Scar Coverage

Other (please explain): ______

Hair restoration solutions of interest:

NeoGraft FUE Surgical hair restoration (Follicular-unit transplantation extraction: FUE/FOX) transplantation Medical therapy (Propecia, Minoxidil/Rogaine) / transplantation Laser hair therapy (laser hood, laser comb) Body-hair transplantation Nutritional supplementation Scar coverage Post-Plastic Surgery hair transplantation (describe below)

Where are you in the hair restoration process?

I've started researching my hair restoration options I've had a consultation with another doctor

I'm interested in starting non-invasive treatment (Propecia, I'm interested in scheduling a surgical procedure within the Minoxidil /Rogaine, Laser Therapy) next ninety days

I've had a hair transplant before I'm interested in scheduling a surgical procedure within the next year

How many grafts are you interested in transplanting?

I don’t know. Less than 1,000  Less than 2,000  More than 2,000 

Patient Comments Do you have any concerns with the hair the hair transplant procedure? Yes____ No____

If yes, what are they? ______

North Valley Plastic Surgery Hair Loss Consult Form

Estimate of Hair Grafts in Hair Transplant Procedure* *Some patients may require a second treatment to achieve the necessary hair density.

Norwood Class Follicular Unit Grafts With Crown**

I Under 800

IIa 800-1400 -

III 1000-1600 -

III Vertex 1200-1600 1600-2200

IIIa 1400-1800 -

IV 1600-2200 2200-2600

IVa 1800-2400 -

V 2000-2500 2500-2800

Va 2200-2800 -

VI 2400-3000 2800-3400

VII 2500-3200 3000-3600