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"On line” consultation by a medical specialist

NOTE :
This "on line” consultation is performed by a medical specialist. This will allow all people to receive all the information and documentation required for such operation. If there is operation, the previous day it will carry out a surgery with the doctor, in the same place where the operation took place.

PHOTOS : In addition to this form, it is important to send us 2 photographs by email. These photographs must be the front of the head slightly towards the top and the crown with your head tilted to see the top of it. If you have a little height or density crown you should send a third photo to the following address: contact@greffedecheveux.org.

ALL THE INFORMATION TRANSMITTED IN THIS ”ON LINE” CONSULTATION IS ESSENTIAL TO SEND YOU AN APPROPIATE REPLY:
A COMPLETE SHEET OF THE OPERATION (INFORMATION, COMPLETE ARCHIVES OF THE OPERATION WITH INFORMATION, MEDICAL PRESCRIPTION, CONTRACT AND BUDGET...). WE RESPECT A TOTAL AND COMPLETE CONFIDENTIALITY ON YOUR PERSONAL DETAILS.

*
Please do not omit indicate your email address, otherwise we would not send you our reply.Thanks.
Surname : Name :
Sex : Male Female Proffesion :
Age : Date of birth :
Adresse :
City : Post code : Country :
Phone : Fax : Mobile :
Email * :
CLINICAL HISTORY
At what age did you begin to lose hair? years old
Has your hair loss been constant from the beginning? Yes No
Did you have any more intensive hair loss period? Yes No
Has your hair loss decreased nowadays? Yes No
For women
according to Ludwig’s images (images bellow) which number corresponds to you?

For men
according to Hamilton’s images (images bellow) which number corresponds to you?

Send us two photos: one of them front and the other the top of the head, send us a third photo in case of a weak donor area.
Each photo should not exceed 400kb.
Attach these photographs by clicking here, indicating in the e-mail subject: "Photo questionnaire”, name and surname..
Is there anybody in your family with hair loss?
Father : Yes No Which number would you give him? Age ?
Brother : Yes No Which number would you give him? Age ?
Paternal grandfather : Yes No Which number would you give him? Age ?
Mother grandfather : Yes No Which number would you give him? Age ?
Great-grandfather : Yes No Which number would you give him? Age ?
Uncle : Yes No Which number would you give him? Age ?
Cousin : Yes No Which number would you give him? Age ?
TRAITEMENTS ANTERIEURS
Avez-vous déjà suivi un traitement contre la chute de cheveux ? Yes No
Minoxidil Propecia Polyvitaminés Others :
What is your level of satisfaction ?
Very satisfied Satisfied
Acceptable Unsatisfied
Hair prosthesis :

Type :

Date :

Duration :

years
«Thick implants» by surgery :
No Yes

Number of grafts :

Number of strip(s) :

Reduction of the crown :
No Yes

Date :

Micrografts :
No Yes

How many ? :

Number of grafts :

Dates :

Number of strip(s) :

YOUR HAIR
Your hair is : What is your natural colour?
Very fine Roux
Fine Blonds
Half fine Clear brown
Thick Dark brown
Straight Black
Wavy Grey
Curly White
Density of the "crown” : good half density weak
Height in the rear of the crown : cm (from bottom to the top)
How do you comb ?
backward With stripe in the middle very short
Forward With stripe on the left medium length
With stripe on the right long
The density of the hair located on the nape is...:?
important
medium
weak
OPERATION
What area do you want us to implant?
front Receding hairline On the top (vertex) crown "strips”
Do you want an implant forward? : Yes
No
Do you want an implant backward? : Yes
Non
Do you have sensibility to injections? :
(pain, sickness…)
Yes
Non
You want... : a total anesthesia (mask)
a local anesthesia
You want to carry out an implant : maximum grafts in a single time
with two operations

GENERAL HEALTH QUESTIONNAIRE

MEDICAL BACKGROUND
Show the surgical operations that have done throughout your life :
ANTÉCÉDANTS MÉDICAUX
What major diseases have you had throughout your life ?
What kind of medicine do you have now ?
Do you have any chronic illness ? Which ?
Do you have any illness today ? Which ?
Do you have any mental disorder nowadays ? Which ?
Are you taking any medication ? Which ?
Do you have allergies ? Why ?
Are you in an anxiety period ? Yes No
Are you in a depression period ? Yes No
Do you smoke ? Yes No
How many cigarettes ? /days
Do you often drink alcohol ? Yes No
what ?
Number of glasses /days
Do you take toxic substances ? Yes No
Do you bleed easily ? (brushing teeth, the dentist, a wound….) Yes No
Do you have previous cases of haemophilia in your family ? Yes No
COMMENTS OR QUESTIONS...
Height : Blood pressure :
Weight :
You want :
to receive only a reply by email
to have a direct communication with the doctor
Evening time :
Contact telephone :
to have an appointment
day(s) :
month :
receive additional information
by phone
by email




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Advantages and drawbacks.
The essentials 
 Vocabulary
 Comparisons
 Why the 2 MM
 The operation
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