HAIR SITUATION :: Mathis Medical Marketing & Management GmbH

Please fill out the form below to the best of your ability. This will take it easier for us to assess your hair situation. Thank you.

Affected sites

Hair line :

serious hair loss thin very thin bald

Hair line :

serious hair loss thin very thin bald

Crown :

serious hair loss thin very thin bald

schütter

sehr schütter

kahl

starker Haarausfall= Praventivbehandlungen werden empfohlen
schutter= 1 Behandlung
sehr schutter= 1-2 Behandlungen
kahl= 2-3 Behandlungen

Hair structure

Personal details

weiblich männlich

Alter 18 - 22 Jahre Alter 23 - 35 Jahre Alter 36 - 45 Jahre mehr als 45 Jahre

Allgemeines

Have you already tried other methods? :

Yes No

If yes, which ones? :

How often do you wash your hair? :

Is your hair normal, dry, oily, dandruffy? :

Requirements

Haaransatz neu gestalten etwas auffüllen, ergänzen Haardichte wie mit 15 Jahren

Family history

Please enter hair situation using the numbers in the graph above.

father :

brother :

paternal grandfather :

maternal grandfather :

paternal uncle :

maternal uncle :

General medical history - personal and confidential Important questions concerning your health

To the best of your knowledge are you in good health? :

Yes No

Have you been ill during the last 12 months? :

Yes No

Do you suffer or have you ever suffered from:

skin allergies or eczema :

Yes No

drug allergies :

Yes No

iodine allergy :

Yes No

penicillin allergy :

Yes No

anaemia :

Yes No

asthma :

Yes No

bronchitis :

Yes No

diabetes :

Yes No

epilepsy :

Yes No

Do you have any head scars? :

Yes No

Have you had any operations? :

Yes No

If so, what? :

Have you ever had an AIDS test? :

Yes No

hepatitis :

Yes No

heart problems :

Yes No

high blood pressure :

Yes No

low blood pressure :

Yes No

headaches :

Yes No

predisposition to excessive scarring :

Yes No

predisposition to excessive bleeding :

Yes No

Do you take medication regularly? :

Yes No

If so, which? :

Do you take drugs? :

Yes No

blackouts or fits :

Yes No

Do you tolerate local anaesthetics during dental treatment? :

Yes No

When did you last have a medical check-up :

Thank you for taking the time to fill in these details. You have now completed the first step.

With this information we can now offer you advice appropriate to your personal situation. A consultation lasts 1 to 1½ hours.

Ja, ich wünsche eine persönliche und unverbindliche Beratung (Kosten Fr. 95.00, inkl. schriftlicher :

Preferred time of day :

morning afternoon

Preferred day of the week :

Specific time of day (will be confirmed within 24 hours) :

My address

Surname :

First name :

Street :

Postcode :

Country :

Telephone :

Telefon Geschäft :

Fax :

E-Mail :

best time to call :

Remarks :

Confirm Security Code :