Hair Loss | Questionnaire

What is your type of hair loss?

Genetic/Mild Hair Loss

Receding Hairline

Thin crown

Thinning all over

Extensive Hair loss

Patchy

Completely bald

Genetic/Mild Hair Loss

Receding Hairline

Thin crown

Thinning all over

Extensive Hair loss

Patchy

Completely bald

when did you first begin to notice your hair loss ?

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My hair loss has been sudden and I’ve noticed over the past few days / weeks

I have had gradual hair loss which I have noticed over the past couple of months / years

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Have you experienced hair loss anywhere else on your body?

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Yes

No

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Please tell us about hair loss in areas other than your head.

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Have you taken any of these medications consistently over the last 12 months:Minoxidil (also known as Regaine) or Finasteride (also known as Propecia)?

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Yes

No

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Please tell us what medication you've taken, its effectiveness, and any side effects.

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Do you have any scalp problems?

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Yes

No

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Please select your scalp problems?

Psoriasis

Sunburn

Sudden soreness/redness

Dandruff

other

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Are any of the following true?

I have previously been diagnosed with breast cancer, prostate cancer, or I am currently undergoing PSA (prostate monitoring).
I have uncontrolled low or high blood pressure.
I am experiencing, or have previously experienced, depression, anxiety, or panic disorders.

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Yes

No

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Have you previously been diagnosed with breast cancer, prostate cancer, or are you currently undergoing PSA (prostate monitoring)?

Yes

No

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Are you experiencing, or have previously experienced, depression, anxiety or panic disorders?

Yes

No

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Patients treated with finasteride, have had reports of mood alterations including depression and although less frequently, suicidal ideation

I understand and agree to stop this treatment immediately and consult a doctor if I experience symptoms of depression, anxiety, or panic disorders.

I am not currently stable or don't want to proceed with Finasteride.

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Do you have uncontrolled low or high blood pressure?

Yes

No

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Do you have any of the following problems?

Significant or Chronic Kidney Disease
Phaeochromocytoma
Heart attack, stroke, or mini-stroke within the last 6 months
Chest pain symptoms or any heart rhythm issues
Heart valve problems
Disease of the heart muscles
Get breathless or have chest pain with light exertion, such as walking briskly for 20 minutes or climbing two flights of stairs

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Yes

No

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Do you have any intolerances/allergies to the following?

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Lactose

Minoxidil

Finasteride

None

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If we recommend a tablet medication in your plan it can contain very small amounts of lactose. If you have previously taken most tablet formulations without causing any symptoms then it is unlikely that you will get undesirable effects from the lactose within our tablets. Are you okay to proceed?

Yes

No

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Please Inform Us About Any Major Illnesses, Ongoing Medical Conditions, Medications (Prescribed Or Over-The-Counter) You Take, Allergies To Medication, Or Surgeries. This Information Is Necessary For Our Clinicians To Ensure The Prescribed Treatment Is Safe For You.

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I have a major illness, ongoing medical condition, allergy to medication, or take prescribed or over-the-counter medication to inform you about.

I do not have a major illness, ongoing medical condition, operation, allergy to medication, or take prescribed or over-the-counter medication to inform you about.

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Would you like us to inform your GP about your treatment?

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Yes

No

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Please provide your GP's name and address.

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Thank you

For Answering

Thank you for answering questions about your health and experiences with hair loss. Your responses will assist our licensed clinicians in determining if a prescription for hair loss treatment could be appropriate for you. They will promptly review your answers and get back to you with suitable suggestions.

Before Submitting Your Answers, PleaseAcknowledge The Following:

You Are The Sole User Of Any Medication Provided Through This Service.
You Have Provided Truthful Answers To The Best Of Your Knowledge.
You Are Aware That Minoxidil 5% Solution And Combined Minoxidil 5% With 0.1% Finasteride Solution Are Prescribed As Unlicensed Products.
You Were Assigned Male At Birth.
You Have Disclosed Any Serious Illnesses Or Operations You Have Had.
You Have Disclosed Any Prescription Medication You Currently Take.
You Will Only Use The Recommended Method Of Hair Loss Treatment And Not Combine More Than One Different Medication For This Condition.
You Are Aware That You Should Not Take Finasteride If You’re Trying For A Baby.
You Accept Our Terms & Conditions, Privacy Policy, And Terms Of Sale.
You Currently Live In The UK.
You Are Using This Service Of Your Own Free Will.
Will Read all patient information leaflets available
You Agree To The Terms Of Service, Terms Of Subscription, And Privacy Policy.

What is your type of hair loss?

when did you first begin to notice your hair loss ?

Have you experienced hair loss anywhere else on your body?

Please tell us about hair loss in areas other than your head.

Have you taken any of these medications consistently over the last 12 months:Minoxidil (also known as Regaine) or Finasteride (also known as Propecia)?

Please tell us what medication you've taken, its effectiveness, and any side effects.

Do you have any scalp problems?

Please select your scalp problems?

Are any of the following true?

Have you previously been diagnosed with breast cancer, prostate cancer, or are you currently undergoing PSA (prostate monitoring)?

Are you experiencing, or have previously experienced, depression, anxiety or panic disorders?

Patients treated with finasteride, have had reports of mood alterations including depression and although less frequently, suicidal ideation

Do you have uncontrolled low or high blood pressure?

Do you have any of the following problems?

Do you have any intolerances/allergies to the following?

If we recommend a tablet medication in your plan it can contain very small amounts of lactose. If you have previously taken most tablet formulations without causing any symptoms then it is unlikely that you will get undesirable effects from the lactose within our tablets. Are you okay to proceed?

Please Inform Us About Any Major Illnesses, Ongoing Medical Conditions, Medications (Prescribed Or Over-The-Counter) You Take, Allergies To Medication, Or Surgeries. This Information Is Necessary For Our Clinicians To Ensure The Prescribed Treatment Is Safe For You.

Would you like us to inform your GP about your treatment?

Please provide your GP's name and address.

Thank you

For Answering

Before Submitting Your Answers, PleaseAcknowledge The Following:

1000+

1000+

Extensive Hair Loss

We’ve got you Covered

Manny A.

What is your type of hair loss?

when did you first begin to notice your hair loss ?

Have you experienced hair loss anywhere else on your body?

Please tell us about hair loss in areas other than your head.

Have you taken any of these medications consistently over the last 12 months:Minoxidil (also known as Regaine) or Finasteride (also known as Propecia)?

Please tell us what medication you've taken, its effectiveness, and any side effects.

Do you have any scalp problems?

Please select your scalp problems?

Are any of the following true?

Have you previously been diagnosed with breast cancer, prostate cancer, or are you currently undergoing PSA (prostate monitoring)?

Are you experiencing, or have previously experienced, depression, anxiety or panic disorders?

Patients treated with finasteride, have had reports of mood alterations including depression and although less frequently, suicidal ideation

Do you have uncontrolled low or high blood pressure?

Do you have any of the following problems?

Do you have any intolerances/allergies to the following?

If we recommend a tablet medication in your plan it can contain very small amounts of lactose. If you have previously taken most tablet formulations without causing any symptoms then it is unlikely that you will get undesirable effects from the lactose within our tablets. Are you okay to proceed?

Please Inform Us About Any Major Illnesses, Ongoing Medical Conditions, Medications (Prescribed Or Over-The-Counter) You Take, Allergies To Medication, Or Surgeries. This Information Is Necessary For Our Clinicians To Ensure The Prescribed Treatment Is Safe For You.

Would you like us to inform your GP about your treatment?

Please provide your GP's name and address.

Thank you For Answering

Before Submitting Your Answers, PleaseAcknowledge The Following:

1000+

1000+

Your safety is our top priority.

Unfortunately, We can’t offer you any Hair Loss medication.

Your safety is our top priority.

Unfortunately, We can’t offer you any hair growth medication.

Did you make a mistake?

Extensive Hair Loss

We’ve got you Covered

Manny A.

Thank you

For Answering

Your safety

is our top

priority.