Hair Loss

Kindly ascertain that the intended user is between the ages of 18 and 65.
Do you require assistance?

Yes

No

Are you currently receiving any treatment or medication?

Please provide more information of the medication being used if any.

Yes

No

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Can you relate to any of the following?

You have an underlying medical condition You've been through a major surgical procedure You have allergic reactions You have cardiovascular conditions, including high blood pressure or might have had suffered a stroke You suffer from a low liver or kidney function

Yes

No

Are you aware of the following?
It has been proven that taking more than the suggested amount of a hair loss therapy does not boost its effectiveness.
If your spouse is pregnant or could become pregnant, you should use a condom during any sexual activity and don't let them handle hair loss therapy.
If you need a PSA blood test, notify your doctor that you are taking hair loss treatment because it may impact the findings.
If you have any unusual side effects while taking finasteride or dutasteride, you should consult your doctor. These include breast tissue changes such as lumps, larger breasts, discomfort or nipple discharge, a decreased libido, erectile dysfunction, and ejaculation disorders, as well as a decreased libido, erectile dysfunction, and ejaculation disorders.

Yes

No

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. Do you require assistance?

Yes

No

Are you getting treated or tested for the following conditions:

Changes in your breast tissue, such as lumps, larger breasts, soreness, or nipple discharge melancholy, anxiety, or low mood If you answered yes, please include as much information as possible, including any medications you are taking. Do you require assistance?

Yes

No

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 advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Your doctor has ever told you that your kidney function is less than 100 percent.
You have previously suffered a terrible reaction to aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
You want to use Ibuprofen Gel on skin that is fractured, injured, diseased, or infected.

Yes

No

Are you aware that Finasteride (Propecia) may be present in sperm and that you must use a condom during sexual activity when taking this medication?

Yes

No

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

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

No

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

Yes

No

Do you suffer from any scalp conditions (such as fungal infection)?

Yes

No

Is your hair loss accompanied by any red, inflamed, scaly or itchy skin?

Yes

No

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

Yes

No

Have you had any rapid weight loss in the past 6 months?

Yes

No

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

Yes

No

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

Yes

No

Do you have any problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption?

Yes

No

Do you have any chronic medical conditions (e.g. cancer)?
If yes, please provide details

Please provide details in this box here...

Yes

No

Do you have any allergies?
If yes, please provide details

Yes

No

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

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

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

All Conditions

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