Pre-Operative Questionnaire Hasson & Wong Pre-Operative Patient Questionnaire "*" indicates required fields Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobile PhoneEmail Date of Birth* MM slash DD slash YYYY Your Weight*Weight Units* Pounds Kg Your Height*Height Units* Feet/Inches Meters/CM What is the Date of your Surgery?* MM slash DD slash YYYY Who is your Surgeon?* Dr. Hasson Dr. Wong Surgery and RecoveryI 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.* Yes No I understand what the F.U.T. (Strip method) is and that it will be used to extract donor hair during my surgery. FUT Extraction* Yes No QuestionnaireHave you ever had a heart attack* Yes No Heart Attack DescriptionHave you ever had heart failure or fluid in your lungs?* Yes No Heart failure or lung fluid descriptionHave you ever had a heart murmur or valve problems?* Yes No Heart murmur or valve problems DescriptionHave you ever been treated for an irregular heart beat?* Yes No Iirregular heart beat descriptionDo you have high blood pressure?* Yes No High blood pressure descriptionDo you have asthma?* Yes No Asthma descriptionDo you now or have you recently smoked cigarettes?* Yes No Smoking descriptionDo you cough frequently or have bronchitis or emphysema?* Yes No Description of cough or bronchitis or emphysemaDoes climbing one flight of stairs or walking one city block make you short of breath?* Yes No Short of breath descriptionDo you have liver disease, or a history of jaundice or hepatitis?* Yes No Liver disease, or a history of jaundice or hepatitis descriptionDo you have Obstructive Sleep Apnea (OSA)?* Yes No Describe your sleep apnea?Do you drink more than three drinks of alcohol per day?* Yes No Alcohol descriptionDo you have indigestion, heartburn, or a hiatus hernia?* Yes No Indigestion, heartburn, or a hiatus hernia descriptionDo you have a history of thyroid problems?* Yes No Thyroid problem descriptionDo you have diabetes?* Yes No Diabetes descriptionDo you have kidney problems?* Yes No Description of kidney problemsDo you have numbness or weakness of your arms or legs?* Yes No Description of weakness or numbnessHave you had epilepsy, blackouts, seizures or a stroke?* Yes No Describe epilepsy, blackouts, seizures or strokeHave you had problems with blood clots or excessive bleeding?* Yes No Describe blood clots or excessive bleedingDo you have any other important medical problems?* Yes No Describe other medical problemsHave you ever had local anesthetic?* Yes No Have you ever had any complications from local anesthetic? Please describe the circumstances.Do you apply Rogaine/Minoxidil to your scalp?* Yes No How often and at what strength?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?* Yes No If Yes, how many times per day and at what strength?Do you have any food or drug allergies, including an allergy to latex?* Yes No List allergiesPlease describe the reaction(s) you have to any above mentioned allergiesAre you currently taking any medications?* Yes No Please list the medication name and daily dosage including strength.Have you had keloid scarring? (a medical condition of scar tissue overgrowth)* Yes No Please describe your scarringAre you aware of ever having carried or been treated for an antibiotic resistant organism (ARO)?* Yes No Please explain your ARO treatmentHave you been admitted to a hospital for more than 48 hours within the last 3 months?* Yes No Recently Hospitalized?Are you or have you been treated for alcohol, illicit drug or prescription drug abuse?* Yes No Please explainDo you have a skin infection, any skin lesions or open wounds?* Yes No Please explainNameThis field is for validation purposes and should be left unchanged. Δ
