Strathearn Health and Beauty PRP Questionnaire

Patient Details

Are you currently Pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Emergency Contact Details

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship to Patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient GP Details

GP's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Surgery/Practice Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Surgery Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

We recommend to all our patients that their relevant medical professional i.e. GP should be informed about the treatment. In certain circumstances, Strathearn Health & Beauty may contact your GP or medical professional regarding your treatment.

Please Specify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Your Medical History

Have you ever suffered from any of the following? (Please tick all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please Describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you taking medication for the above condition? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes please describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you been prescribed any of the following? (Please tick all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What condition was this used to treat? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

When did you last take a dose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently taking any other medications or herbal supplements? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list your current medications:

Medication Name

Dosage

what is it used to treat?

Date of last dose?

Medication {binding ItemNumber}

Medication Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dosage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

what is it used to treat? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last dose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please Tick if any of the following applies to you: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Location of Plates/Pins {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medical Investigations/Operations

Condition or Illness

Treatment Received

Treatment Date

Are you due a follow up?

Item {binding ItemNumber}

Condition or Illness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Treatment Received {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Treatment Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you due a follow up? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You smoke? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do You Drink Alcohol? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How many cigarettes would you smoke in an average day? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How many units of alcohol would you consume in an week? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Consent to Lesion Removal

By signing below the patient confirms that they:

Consent to PRP Hair procedure as described by the practitioner.
Agree to follow all pre and post care instructions which will be fully explained, and a copy suppled to the patient.
Consent to the taking and storing of photographs with the understanding that they will be used ONLY for the purpose of the treatment.
Consent to allow Strathearn Health and Beauty to contact the patient’s GP or healthcare provider regarding the procedure if deemed necessary and/or appropriate by the performing surgeon.
I understand that the results of this treatment vary considerably and a small percentage of people may not respond to the treatment.
I understand that multiple treatments will be required to achieve satisfactory results.
I understand that there may be some short-term side effects such as reddening of thie skin, bruising and swelling.
I understand that local anaesthetic may be used during the course of my treatment.

Patient Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please specify the location of the Area to be treated: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please use the button below to upload any photos of the treatment area and/or any relevant letters from GP or health professionals. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

By clicking “Submit” you are agreeing to all Strathearn Health and Beauty Terms & Conditions and declare that all supplied information is accurate and up to date.