Online Medication Assessment

Your Consultation

We will ask you a few questions to assess your suitability for prescription hair loss medication. It should take approximately 5 minutes to complete. This questionnaire will provide us with information about your hair loss. Although we aim to make our form simple and comprehensive; on occasion and only when necessary we will contact you for further information. It is important, to be honest and if you are unsure about any of the questions it is always worthwhile speaking to your GP.

I will see my GP if I need help completing this form, reading or understanding this consultation.
I am using this service on my own behalf and of my own free will and any treatment or advice is for my sole use only.
I understand that my prescription will not be approved until a doctor has reviewed and confirmed suitability for hair loss medication.

Consent(Required)

I have read and can confirm my understanding of the above.

When did you first notice you were losing hair?(Required)

Does anyone in your family suffer from hair loss?(Required)

What side of the family?(Required)

Fathers Side

Mothers Side

Fathers and Mothers Side

Have you noticed any other changes to the areas where you are losing hair?(Required)

Yes

Such as redness, itching, flaking or soreness

Please describe the changes(Required)

Have you been diagnosed with Androgenic Alopecia (Male/Female Pattern Baldness)?(Required)

Yes, by my GP

Yes, by a specialist

No, self-diagnosed

Which of the following best describes your hair loss? (Tick all that apply)(Required)

Temples only (receding at the front)

Temples and Crown

Random patches - more details

Complete

Have you lost any hair elsewhere on your body?(Required)

Yes

Please give details(Required)

Have you tried any hair loss treatments before?(Required)

Yes

Please list any treatments(Required)

For example: Finasteride, Propecia, Dutasteride, Minoxidil, Supplements

Was it effective? Did you have any side effects?(Required)

Have you had any previous hair loss procedures?(Required)

Yes

Please provide details of previous procedures(Required)

Do you have any conditions affecting your liver, kidneys, prostate or urinary system?(Required)

Yes

Please provide details of any conditions(Required)

Are you taking any medication for high blood pressure (hypertension)?(Required)

Yes

Please provide details of any blood pressure medication(Required)

Are you taking medication for a prostate condition?(Required)

Yes

Please provide details of prostate medication(Required)

You also need to know that these medicines can affect prostate blood test results. So if you need a prostate blood test, tell your doctor that you take finasteride or propecia. I understand that if I need a prostate blood test, the doctor will need to know I am on this medicine.

Are you currently taking any other medication, or have you recently finished a course of medication?(Required)

Yes

Please provide details of any other medication you are taking or have recently finshed(Required)

Are you allergic to any medicines or other substances?(Required)

Yes

Please list any allergies

Do you have any skin conditions?(Required)

Yes

Please provide details of any skin conditions

For example: Keloids, Seborrheic Eczema, Dermatitis, Psoriasis etc

Are you or your partner pregnant or trying to get pregnant?(Required)

I am pregnant

My partner is pregnant

Trying to get pregnant

If you or your partner is pregnant you must use condoms while taking finasteride or Propecia to prevent harm to the baby. <br>Please confirm that you understand this.(Required)

I confirm that I understand

Depression

Some people taking Finasteride or Dutasteride medication have experienced mood swings. You should stop taking this either of these medications immediately if you notice that your mood is affected and speak to your doctor.

Consent(Required)

Please tick if you understand this and wish to continue. You can contact us if you have any questions

Erectile Dysfunction

One of the side effects of finasteride and Propecia, which occurs in around 2% of men, is problems with sexual function, including erectile dysfunction, meaning your symptoms of ED may worsen.

Consent(Required)

Please tick if you understand this and wish to continue. You can contact us if you have any questions

Please provide us with pictures of your hair to aid us with your assessment

Front View(Required)

Max. file size: 64 MB.

Side View

Max. file size: 64 MB.

Back View

Max. file size: 64 MB.

Top of Head View

Max. file size: 64 MB.

Name(Required)

First Last

Occupation(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Address

Street Address City ZIP / Postal Code

Consent(Required)

I fully understand the questions asked and have answered honestly and truthfully.

HR Medication Assessment

Your Consultation

Depression

Erectile Dysfunction

Please provide us with pictures of your hair to aid us with your assessment

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