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Submit Medical History

Complete Your Medical History
Before booking your first consultation, please fill out the Medical History Form.

 

Upload Photos
Take 2 clear photos of your scalp and upload them along with your Medical History Form.

My Medical History

Please complete all the fields.

Birthday
Day
Month
Year
What brings you in today?

e.g: 3 Months, 4 Years

Is the hair loss gradual or sudden?

e.g: Yes, my mother

Do you have or had any of the following conditions?

e.g: Thyroxine

e.g: Vitamin D

e.g: 2 times per week

Do you use any of the below?
Have you noticed breakage or hair falling from the root?
No, I didn't notice
Yes, breakage
Yes, falling from the root

e.g: Yes, I'm VEGAN, I'm Vegetarian, I don't eat meet, etc.

Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Have you had significant or gain recently?
No
Yes, weight loss
Yes, gain weight
Are you currently experiencing high stress?
Yes
No
Have you had a baby in the past year (for women)?
Yes
No
Are your periods regular (for women)?
Yes
No
Wich type are you?

Upload up to 2 pictures

By submitting your medical information and photos, you consent to their use by Dr. Goudelas and the clinic’s medical staff solely for diagnostic and treatment purposes, in accordance with privacy regulations.

All medical history information is handled with strict confidentiality and securely protected in compliance with healthcare privacy regulations.

current hair condition

Dr. Stefanos Goudelas | Dermatologist
Expert in Cosmetology & Hair Loss

Opening Hours

Monday - Friday: 9 AM - 6 PM
Saturday - Sunday: Closed
Public Holidays: Closed

Contact Us 

​​

Add: Menandrou 12, Eliona Tower, Ap.201,

1066 Nicosia - Cyprus

​

T: +357 22 31 66 60

M: +357 99 17 17 91

e: drstefanosgoudelas@gmail.com

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