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Pre-Operative Questionnaire - FUE

Hasson & Wong Pre-Operative Patient Questionnaire

"*" indicates required fields

Name*
Address*
MM slash DD slash YYYY
Weight Units*
Height Units*
MM slash DD slash YYYY
Who is your Surgeon?*

Surgery and Recovery

I understand the recipient area of my scalp will have dry skin or may have scabs on it for the first 7-10 days post-op and that I may experience redness for up to 4-6 weeks after surgery. Additionally, I understand that I may experience facial swelling in the first week which could prevent me from resuming normal activities or working.*
I understand what the F.U.E. (punch method) is and that it will be used to extract donor hair during my surgery.
FUE (punch) Extraction*

Questionnaire

Have you ever had a heart attack*
Have you ever had heart failure or fluid in your lungs?*
Have you ever had a heart murmur or valve problems?*
Have you ever been treated for an irregular heart beat?*
Do you have high blood pressure?*
Do you have asthma?*
Do you now or have you recently smoked cigarettes?*
Do you cough frequently or have bronchitis or emphysema?*
Does climbing one flight of stairs or walking one city block make you short of breath?*
Do you have liver disease, or a history of jaundice or hepatitis?*
Do you have Obstructive Sleep Apnea (OSA)?*
Do you drink more than three drinks of alcohol per day?*
Do you have indigestion, heartburn, or a hiatus hernia?*
Do you have a history of thyroid problems?*
Do you have diabetes?*
Do you have kidney problems?*
Do you have numbness or weakness of your arms or legs?*
Have you had epilepsy, blackouts, seizures or a stroke?*
Have you had problems with blood clots or excessive bleeding?*
Do you have any other important medical problems?*
Have you ever had local anesthetic?*
Do you apply Rogaine/Minoxidil to your scalp?*
View a list of common drugs and supplements that cause blood thinning.
Do you take Aspirin (ASA), or drugs and supplements that are known to cause excessive bleeding or bruising?*
Do you have any food or drug allergies, including an allergy to latex?*
Are you currently taking any medications?*
Have you had keloid scarring? (a medical condition of scar tissue overgrowth)*
Are you aware of ever having carried or been treated for an antibiotic resistant organism (ARO)?*
Have you been admitted to a hospital for more than 48 hours within the last 3 months?*
Are you or have you been treated for alcohol, illicit drug or prescription drug abuse?*
Do you have a skin infection, any skin lesions or open wounds?*
This field is for validation purposes and should be left unchanged.

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Located at 1001 West Broadway, Vancouver B.C. Canada