WELCOME TO YOUR HAIR RESTORATION CONSULTATION WITH NORTH VALLEY PLASTIC SURGERY
Name: ______
What is your current hair loss concern?
Starting to thin Increased shedding
Advanced stage of thinning Missing, damaged or sparse eyebrows
Overall thinning Weak or sparse eyelashes
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 Eyelash transplantation extraction: FUE/FOX) Eyebrow transplantation Medical therapy (Propecia, Minoxidil/Rogaine) Beard/moustache 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