1. Eyes
e.g. Infections or Glasses Worn |
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Details About Eyes |
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2. Endocrine System
e.g. Diabetes or Thyroid Disorders |
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Details About Endocrine System |
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3. Cardiovascular System
e.g. High Blood Pressure, Low Blood Pressure, Angina, Heart Attacks |
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Details About Cardiovascular |
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4. Nervous System
e.g. Fits, Faints, Blackouts, Strokes, Migraines |
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Details About Nervous System |
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5. Gastrointestinal
e.g. Weight Loss, Diarrhoea, Constipation, Gastric Ulcers |
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Details About Gastrointestinal |
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6. Psychiatric
e.g. Depression, Chronic Fatigue, Panic Attacks *
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Details About Psychiatric |
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7. Hospital/Clinic/GP Surgery Treatment
e.g. Any Operations or Outpatient Treatment
Any other medical information
For Weight Loss Consultations( Females )
Please indicate if you are pregnant or breast feeding |
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Details About Hospital/Clinic/GP Surgery Treatment |
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8. Current Medication
e.g.Please name the medication, Doses, Frequency, For How Long and For What Condition |
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Details About Current Medication |
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9. Allergies
e.g. To Any Drugs, Foods, Environmental Hazards |
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Details About Allergies |
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10. What is the problem with hair loss? *
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11. How long have you had it for? *
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12. Have you tried any other treatment? |
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Details About Other Treatment |
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