Hair Loss Treatment

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

1

We can treat hair loss in males. Are you male?

This refers to your biological gender

Yes

No

2

Date of Birth

Use the calendar to select your date of birth.

3

Please add your height (in cms).

Your height is important for the prescribers decision.

4

Please add your current weight (in kgs).

Please make sure to add your current weight. This may affect the prescriber's decision.

5

Do you know if your blood pressure is Low, Normal or High? Please write LOW, NORMAL or HIGH

Use the following as a guide:

Low = Under 90/60
Normal = Between 90/60 and 140/90
High = Over 140/90

6

Do you have uncontrolled high blood pressure (hypertension) (e.g. > 145/90 mmHg)

Yes

No

7

Do you have any liver problems (hepatic impairment)?

Yes

No

8

Do you smoke?

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

Yes

No

9

Do you drink alcohol?

If so, please tell us how many units per day. You can use the following as a guide:

- Pint of beer = 3 units
- A can of beer = 2 units
- A large glass of red wine = 3 units

Yes

No

10

Can you walk 3 miles or climb a set of stairs without pain in your chest?

If you cannot, please provide more information

Yes

No

11

Have you previously had a transient ischaemic attack (mini stroke) or stroke?

Yes

No

12

Do you suffer from any allergies?

If you do, kindly explain them below

Yes

No

13

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

No

14

Have you recently finished any course of medication?

Yes

No

15

Have you ever had any surgery (operations)?

If so, please provide more details

Yes

No

16

Do you suffer from bladder obstruction (obstructive uropathy)?

Yes

No

17

Are you being treated or tested for:

1. any problems with your prostate (including enlarged prostate (BPH) and prostate cancer)

2. changes in your breast tissue such as lumps, enlarged breasts, pain or nipple discharge

3. depression, anxiety or low mood.

Yes

No

18

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

No

19

Do you have known or suspected cancer, or have you had cancer in the past?

If yes, please provide details

Yes

No

20

Do you have a history of depression, generalized anxiety disorder or any other psychiatric disorder?

Yes

No

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

21

Please list any hair or scalp treatments which are applied to the scalp that you are currently using

22

Can you relate to any of the following statements?

Your hair loss started recently, and you've lost a lot of hair in less than four weeks.
Hair loss has occurred in irregular spots on your head.
Your scalp is itchy or inflamed.
You've lost your hair as a result of your pharmacological treatment.
You're completely bald or have lost all of your body hair.

Yes

No

23

How long have you been suffering from hair loss (years)?

24

Have you ever used dutasteride (Avodart) 0.5mg capsules to treat your hair loss?

Yes

No

25

Have you ever used Finasteride tablet to treat hair loss?

Yes

No

26

Have you ever used Regaine to treat your hair loss?

Yes

No

27

Did you know that using a higher dose of a hair loss therapy will not improve its effectiveness?

Clinical trials have indicated that the recommended amount is the most effective for hair loss, and that raising your dose or mixing Avodart (dutasteride) and Propecia has no extra benefit (finasteride). Increasing your dose or combining therapies will not improve or speed up your outcomes, but it will make you more susceptible to side effects.

Yes

No

28

Have you had a serious reaction to any hair loss medicines before?

Yes

No

29

Is the hair loss only located at the temples or the side of the forehead?

Yes

No

30

Is your hair loss in clumps/patches, or is the hair loss rapid?

Yes

No

31

Do you understand that regrowth of hair can take up to 6 months and is most effective up to 2 years?

Yes

No

32

Do you agree to tell your doctor or pharmacist about any side effects you may be experiencing with the medicines and any progression of symptoms?

Yes

No

33

Do you understand that any hair growth may be lost 6-12 months after treatment?

Yes

No

34

Are you aware that crushed or broken tablets of finasteride should not be handled by women when they are or may potentially be pregnant?

Yes

No

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

35

Do you agree to the following?

- You declare that I have answered the above truthfully
- You will read the patient information leaflet before taking your medication (if prescribed)
- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment
- You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
- You understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor

Yes

No

36

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Yes

No

37

Would you like a free face to face consultation with our Doctor via Skype video?

Yes

No

Want your order delivered tomorrow?

For next day delivery please order in next:

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Unfortunately we cannot offer you any treatments for this condition.
Please feel free to contact us for more information.

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Complete assessment form

Complete assessment form

Complete assessment form