Rxpress

Hair Loss Consultation Form

Date of Birth (DD/MM/YYYY):

Age:

Full Name:

Home Address:

Email:

Telephone:

Name & Address of GP:

Would you like your GP to be informed of this consultation?
YesNo

NHS Number (optional):

Please answer the following questions

Do you have any recent or past medical history of note?
YesNo

If yes, please provide details:

Do you have any allergies?
YesNo

If yes, please provide details:

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

Do you agree to tell your doctor or supplier about any side effects or progression of symptoms?
YesNo

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

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

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

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

Is the progression of your hair loss symmetrical (same on both sides)?
YesNo

Do you currently have depression, anxiety, psychosis, schizophrenia, or other psychiatric disorder?
YesNo

Is the hair loss only located at the temples or side of the forehead?
YesNo

Do you have a history of depression, anxiety or psychiatric disorder?
YesNo

Is your hair loss in clumps/patches or is it rapid?
YesNo

Do you suffer from bladder obstruction (obstructive uropathy)?
YesNo

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

Do you have any liver problems (hepatic impairment)?
YesNo

Do you have galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption?
YesNo

Are you aware that crushed/broken finasteride tablets should not be handled by women who are or may be pregnant?
YesNo

Do you have any chronic medical conditions (e.g. cancer)?
YesNo

If yes, please provide details:

Are you aware that you should tell your doctor you’re receiving treatment before having a PSA test?
YesNo

Please list all your current prescription medications, including any over-the-counter medicines:

Do we have permission to access your medical records?
YesNo