Hair Loss Medical Assessment

About You

Are you male and aged between 18-65?

Yes

No

This treatment is not suitable for women, or those under 18 or over 65.

Please complete this question.

Have you been taking Finasteride for more than 3 months?

Yes

No

Please complete this question.

Although Finasteride starts working immediately, it can take up to six months to see the benefits of Finasteride.

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We will still be able to offer you treatment, but with a limited range.

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We may still be able to offer you hair loss treatment, but with a limited medicine range after completing the consultation. We recommend consulting NHS services for advice on depression.

Please complete this question.

Your Symptoms

Are you suffering from hair loss?

Yes

No

We are unable to supply you with treatment if you are not suffering from hair loss. Please consult your GP or doctor for more information.

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Could your hair loss be explained by any medication, dietary matter or illness?

Yes

No

If a lifestyle or health factor is causing your hair loss, we recommend speaking to your GP or doctor for further advice.

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Do you have a healthy scalp?

no inflammation on the scalp
no redness
no medical dressings

Yes

No

We are unable to supply you with treatment. Please consult your GP or doctor.

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Do you have hair loss in patches, or have an itchy or sore scalp?

Yes

No

This treatment is not suitable for you. We recommend contacting your GP or doctor for further advice.

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Do you have sudden unexplained hair loss or complete hair loss?

Yes

No

This treatment isn't suitable for this type of hair loss. We recommend you speak to your GP or doctor for further advice.

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Is your hair loss limited to the temple area?

Yes

No

We may still be able to offer you hair loss treatment, but with a limited medicine range.

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Your Health

Are you allergic/hypersensitive to minoxidil, finasteride/propecia, ethanol, propylene glycol or lactose?

Yes

No

This treatment is not suitable for you.

Please complete this question.

Do you have a history of depression, suicidal thoughts and/or any other mental illness?

Yes

No

We will still be able to offer you treatment, but with a limited product range. We recommend consulting NHS services for advice on depression.

Please complete this question.

Have you ever been diagnosed with one of the following conditions:

Heart disease (including chest pain, angina, heart attack or any history of cardiovascular event)
High blood pressure
Pheochromocytoma (cancer of the adrenal glands)
Male breast cancer
Acute porphyria (a rare hereditary disease affecting haemoglobin)
Prostate problems (prostate enlargement, prostatitis, prostate cancer)
Any liver disease
Obstructive uropathy (difficulty urinating)

Yes

No

This treatment is not suitable for you.

Please complete this question.

Your Medication

Are you currently taking any medication (over-the-counter or prescription) or any recreational drugs?

Yes

No

Are you taking any of the following medications?

Dithranol — used to treat psoriasis
Tretinoin — used to treat acne or other skin disorders
Corticosteroids — hydrocortisone or betamethasone dipropionate
Petrolatum — a common ingredient in hair wax and gel
Already taking a 5AR inhibitor (e.g. Finasteride, Dutasteride)

Yes

No

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

Please complete this question.

Agreement

Do you understand that if you are prescribed finasteride and your partner is (or may be) pregnant, they should not handle crushed or broken tablets, and that you should always wear a condom during sex?

Yes

No

We are unable to supply you with treatment unless you understand and agree to this point.

Please complete this question.

Do you understand that if you are prescribed finasteride, you should inform your GP of this before undergoing a PSA blood test for your prostate?

Yes

No

We are unable to supply you with treatment unless you understand and agree to this point.

Please complete this question.

Do you understand that if you and/or your partner are planning to conceive, finasteride may temporarily impact your fertility? However, this is not common and usually resolves over time after stopping the treatment.

Yes

No

We are unable to supply you with treatment unless you understand and agree to this point.

Please complete this question.

Do you understand that taking finasteride can cause side effects such as depression and may lead to suicidal thoughts? If you experience these symptoms, stop taking finasteride and contact your doctor for further medical advice as soon as possible.

Yes

No

We are unable to supply you with treatment unless you understand and agree to this point.

Please complete this question.

Do you understand that taking finasteride can cause side effects like decreased sex drive and erectile dysfunction which may continue after treatment is stopped?

Yes

No

We are unable to supply you with treatment unless you understand and agree to this point.

Please complete this question.

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, you start new medication and/or your medical conditions change during treatment
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
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 whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

No

You must agree to this before continuing. If you need assistance contact our customer support.

Please complete this question.

Medical Assessment for Hair Loss

To help us supply you with the most suitable treatment, please complete this online consultation.

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