Rx Health Assessment

Your Name

First Name

Last Name

Date of Birth

What gender were you assigned at birth?

Genetically Male

Genetically Female

Are you currently pregnant, breastfeeding, or planning to get pregnant in the next 6 months?

YESNO

Please provide additional information on your childbearing potential.Choose below:

I am post-menopausal

I do not have childbearing potential due to a permanent surgical procedure or other reason

I have childbearing potential but am on birth control

I have childbearing potential and do not use any birth control method

When did you first notice hair loss or hair thinning?Choose below:

Not started yet, I'm trying to prevent it

Recently within the last month

Over the last 6 months to a year

Over a year

On what areas are you experiencing hair loss or thinning?Select all the conditions that apply to you:

No significant hair loss yet, I'm trying to prevent

Hairline (Front)

Crown and hairline

Diffuse across entire scalp

Eyebrows/eyelashes

Other

Have you ever had your hair loss evaluated by a physician?

YESNO

Have you been given a diagnosis?Select all the conditions that apply:

Androgenetic alopecia

Alopecia areata

Discoid Lupus

Frontal Fibrosing Alopecia

Traction alopecia

Telogen effluvium

Other hair loss diagnosis

I have not been given a diagnosis

Some signs and symptoms may indicate that you have other causes contributing to your hair loss aside from pattern hair loss (androgenetic alopecia):Select all the conditions that apply:

Bumps, sores, or rashes on your scalp

Complete loss of hair over entire scalp (including very back of the head)

Hair loss on other parts of my body like eyelashes/eyebrows

Hair loss started during or after a major medical or life event (such as a new medical diagnosis, new medication, major life stressor/trauma, surgery, or cancer therapy)

Itching, burning, redness, and/or scalp tenderness

I regularly wear my hair in ways that can stress my hair/scalp, including tight braids, hair weaves, locks, ponytails, or I use excessive heat and chemicals

My hair loss began before puberty

Smooth round patches of hair loss

Sudden high volume of hair loss/shedding

None of the above

Have you tried any treatments for your hair loss?

YESNO

Please explain what you have tried for treatments of hair loss.

Are you currently on or have you previously tried any of the following hair loss treatments:Select all the conditions that apply:

Bimatoprost

Cetirizine

Ketoconazole Shampoo

Latanoprost

Oral Minoxidil

Oral Spironolactone

Topical Caffeine

Topical Melatonin

Topical Minoxidil (Rogaine)

Topical Spironolactone

Other hair loss treatments

Please describe the results of the treatments you used below.Share more details about the treatments you selected in the previous step. Did you experience any side effects? Please describe below:

Some medical conditions can contribute to hair loss and some can make it unsafe for you to use certain hair loss treatments.Select all the conditions that apply:

Cancer (e.g. prostate, breast)

Eye diseases (e.g. macular disease, retinopathy, uveitis)

Gastrointestinal disorder (e.g. ulcerative colitis)

Heart conditions (e.g. high blood pressure, low blood pressure/orthostatic hypotension, heart failure, angina, abnormal heart rhythm/EKG abnormalities, history of heart attack, history of pericarditis)

Kidney disease/renal insufficiency

Liver disease (e.g. cirrhosis, fatty liver disease)

Rheumatological/bone/joint diseases (e.g. lupus, rheumatoid arthritis, osteoarthritis)

Skin diseases (e.g. psoriasis, eczema)

Thyroid/endocrine/adrenal disease (e.g. hyperthyroidism, Addison’s disease, pheochromocytoma)

No other medical conditions

Vascular diseases (e.g. stroke, blood clots, uncontrolled lower leg swelling)

Other chronic medical conditions

Please share more details about all the chronic conditions you selected in the previous step.Describe below:

How long ago was your most recent check up with a physician?

Within the past year

Within 2 years

Within 3-5 years

Over 5 years ago

At your most recent physician visit, or blood pressure reading, what was the range of your blood pressure:

Low (less than 90/less than 60)

Normal to Mildly Elevated (90-129/60-80)

High (greater than 130/greater than 80)

I do not know my most recent blood pressure reading

Do you have any allergies or intolerances to food, dyes, medications, antibiotics, or anything else.

YESNO

Please list all allergies or intolerances to food, dyes, medications, antibiotics, or anything else.

List all medications and supplements you are prescribed and/or taking. Please separate the list by commas; if you don't take any, please put N/A.

Please introduce yourself and feel free to ask any questions about any medical problems that was not discussed before or include anything else you would like the doctor to know.

Please upload picture of you facing forward and top of your head.* This field is required.Make sure it's a clear picture that shows the affected area(s).

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Please upload a photo of your government issued ID.* This field is required.Make sure it's a clear picture that is not blurry and the data is legible.

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Max. file size: 10.6MB