Hair Loss Consultation Complete this form in order to see what types of hair loss treatments you are eligible for. Step 1/6: Start Leave this field blank Answer these questions to get the most effective clinically proven treatments for you. Full Name Date of Birth Email Please provide an email address so we can contact you furhter regarding enquiries Phone Number Please provide a number so we can contact you furhter regarding enquiries Do you have any recent or past medical history that you think you should tell us about? Yes No Please provide further details Have you had a serious reaction to any hair loss medicines before? Yes No Do you suffer from any scalp conditions? (eg: fungal infections) Yes No Have you had any rapid weight loss in the past 6 months? Yes No Is your hair loss symmetrical? eg: is the hair loss the same on the right as on the left side of your scalp? Yes No Is the hair loss only located the side of the forehead or at the temples? Yes No Are you losing your hair in clumps/patches, or is the hair loss rapid? Yes No Do you have any problems of Lapp lactase deficiency, galactose intolerance or glucose-galactose malabsorption? Yes No Do you have any chronic medical conditions? e.g. cancer? Yes No Please provide further details Do you have any allergies? Yes No Please provide further details Do you agree to tell your doctor or pharmacist about any side affects you may be experiencing with the medicines? 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 treatment? Yes No Is your hair loss accompanied by any red, inflamed, scaly or itchy skin? Yes No Do you have depression, generalized anxiety disorder, psychosis, schizophrenia, or any other psychiatric disorder? Yes No Do you have a history of depression, generalized anxiety disorder or any other psychiatric disorder? Yes No Do you suffer from bladder obstructive uropathy? Yes No Do you have any liver problems? 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 Are you aware that you should tell your doctor you are receiving treatment before having a prostate-specific antigen (PSA) test? Yes No Please list all your current prescription medication including any medication you buy over the counter If you do not have any just leave blank DO YOU AGREE AND CONSENT TO THE FOLLOWING? • I am over the age of 18 years and live in the UK. • I will familiarise myself with the patient information leaflet included with the medication. • I will report any side effects and changes in my health to Bury Healthcare Online and/or your GP. • I will contact Bury Healthcare Online and inform my GP if I experience side effects to any treatment, if my medical history changes, if I start any new medications or if I experience any symptoms or my medical conditions change in any way. • I shall be the sole user of any medication offered to me through this service. • I confirm all answers are provided by me, and will be truthful. I agree to the terms and conditions Next
