About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
Are you between the ages of 18 and 65.
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
What is your biological gender?
Please select your option
Can you relate to any of the following?
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.
How long have you had male pattern baldness?
Please select one option
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.
Have you been using Finasteride tablets to treat hair loss?
Have you been using Regaine to treat hair loss?
If so, for how long have you used it and how successful was it?
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?
Have you previously had a transient ischaemic attack (mini stroke) or stroke?
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.
Do you suffer from any allergies?
If you do, kindly explain them below
Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.
Do you consent to stop the consumption of Finasteride immediately and seek medical help if you experience any of the following symptoms:
Lumps, larger breasts, soreness, or nipple discharge are all signs of breast tissue alterations.
Finasteride can cause mood swings in rare cases.
If you acquire a poor mood, depression, or suicidal thoughts while taking
Finasteride, you should stop taking it and consult your doctor.
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.
If Yes, please proivide as much details as possible
Did you know that Propecia is only for men and that it can affect women, especially those of childbearing age, if they come into contact with it?
Do you have any recent or past medical history of note?
If yes, please provide details
Have you had a serious reaction to any hair loss medicines before?
Do you suffer from any scalp conditions (such as a fungal infection)?
Is the progression of your hair loss symmetrical (the same on the right as on the left side of your scalp)?
Is the hair loss only located at the temples or the side of the forehead?
Is your hair loss in clumps/patches, or is the hair loss rapid?
Do you understand that regrowth of hair can take up to 6 months and is most effective up to 2 years?
Do you have any chronic medical conditions (e.g. cancer)?
If yes, please provide details
Please provide details in this box here...
Do you have any allergies?
If yes, please provide details
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?
Do you understand that any hair growth may be lost 6-12 months after treatment?
Do you have a history of depression, generalized anxiety disorder or any other psychiatric disorder?
Do you suffer from bladder obstruction (obstructive uropathy)?
Do you have any liver problems (hepatic impairment)?
Are you aware that crushed or broken tablets of finasteride should not be handled by women when they are or may potentially be pregnant?
Are you aware that you should tell your doctor you are receiving treatment before having a prostate-specific antigen (PSA) test?
Please list all your current prescription medication including any medication you buy over the counter...
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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.
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, if you start new medication or if 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.