Hair Loss Treatment for Men Risk Assessment Form
About You
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Male
Female
NHS Number (if known)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
What is your ethnicity?
*
Asian or Asian British
Black, Black British, Caribbean or African
Middle Eastern
Mixed or multiple ethnicities with an Asian, Black or Middle Eastern background
White
Other
Name of your General Practice
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
About your health
Do you have any recent or past medical history of note?
*
Yes
No
If Yes please provide details
Do you take any current or repeat medicines? Creams? Other topicals?
*
Yes
No
If Yes please provide details
Have you had a serious reaction to any hair loss medicines before?
*
Yes
No
If Yes please provide details
Do you suffer from any scalp conditions (such as fungal infections)?
*
Yes
No
If Yes please provide details
Have you had any rapid weight loss in the past 6 months?
*
Yes
No
If Yes please provide details
Which symptoms are you experiencing?
Is the progression of your hair loss symmetrical (the same on the right as on the left side of your scalp)?
*
Yes
No
If No please provide details
Is the hair loss only located at the temples or the side of the forehead? Is there any associated redness or inflammation to the scalp?
*
Yes
No
If Yes please provide details
Is your hair loss in clumps / patches? Is the hair loss rapid?
*
Yes
No
If Yes please provide details
Further information about Finasteride 1mg
Do you understand that regrowth of hair can take up to 6 months and is most effective up to 2 years?
*
Yes
No
Do you understand that any hair growth may be lost 6-12 months after treatment?
*
Yes
No
GP Notifications
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? And have a comprehensive review in 2 years from the initial supply?
*
Yes
No
Finasteride 1mg like many other medicines can interact with other medicines you may take; in this respect we recommend that you notify your doctor. Do you agree?
*
Yes
No
Submit
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