Oral Minoxidil Hair Loss Assessment
Answer a few questions and upload photos so your clinician can review whether oral minoxidil may be appropriate for you.
Name
First Name
Last Name
Date of birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
About Your Hair Loss
Where are you experiencing hair loss?
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widening part/top/crown
temples/front hairline
diffuse shedding
round/patchy areas
traction-related loss
receding front hairline with eyebrow thinning/loss
crown loss with scalp pain/tenderness/scaling/shiny skin
eyebrow/eyelash/facial/body hair loss
Other
How long have you noticed hair loss?
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Less than 3 months
3–12 months
1–5 years
More than 5 years
Did the hair loss start gradually or suddenly?
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Gradually
Suddenly
I’m not sure
Which best describes the hair loss pattern?
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More shedding
Gradual thinning
Patchy loss
Combination
Scalp and Possible Triggers
What scalp symptoms or changes have you noticed?
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Redness or significant flaking/scaling
Itching, burning, pain, or tenderness
Pimples, pustules, sores, or drainage
Smooth or shiny areas where hair is no longer growing
None of these
Which possible triggers or recent events may be related to your hair loss?
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Major illness or high fever, including COVID-19
Surgery or general anesthesia
Significant weight loss or restrictive dieting
Pregnancy or childbirth
Significant emotional or physical stress
Started or stopped a medication
Chemotherapy or hormone-blocking cancer treatment
None of these
Other
Do any of your parents or siblings have significant hair thinning or pattern hair loss?
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Yes
No
I’m not sure
Previous Hair-Loss Treatment
Have you tried any previous hair-loss treatment?
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Yes
No
Which previous hair-loss treatments have you tried?
Topical minoxidil (Rogaine)
Spironolactone
Finasteride or dutasteride
Prescription shampoo or scalp treatment
Vitamins or supplements
Platelet-rich plasma (PRP)
Other
Which treatments helped, and how did they help?
If you have used topical minoxidil, why are you interested in another option?
Did not work well enough
Worked initially but improvement plateaued
Irritated scalp
Disliked residue or how hair felt
Too difficult or inconvenient to use regularly
Never tried topical minoxidil
Other
Medical Safety
Are you pregnant, trying to become pregnant, or breastfeeding?
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Yes
No
Not applicable
Have you ever had an allergic reaction to minoxidil?
*
Yes
No
Never used minoxidil
Which of the following conditions have you ever been diagnosed with?
*
Congestive heart failure
Heart attack or angina
Fast or irregular heartbeat/arrhythmia
Pericarditis/pericardial effusion/fluid around the heart
Pulmonary hypertension
Very low blood pressure
Uncontrolled high blood pressure
Kidney disease
Dialysis
Significant liver disease
Significant swelling or fluid retention
Pheochromocytoma/adrenal tumor
None of these
Do you frequently feel dizzy or lightheaded when standing?
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Yes
No
Most recent blood pressure (systolic)
Most recent blood pressure (diastolic)
I do not know my blood pressure
Yes
No
List all prescription medications you currently take, especially medications for blood pressure, heart conditions, or fluid retention
*
List any other significant medical conditions
Hair Photos
Photo Instructions
Front hairline photo
*
Upload a File
Drag and drop files here
Choose a file
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Top of scalp / part photo
*
Upload a File
Drag and drop files here
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of
Crown / back of scalp photo
*
Upload a File
Drag and drop files here
Choose a file
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of
Optional close-up photo of any area of concern
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Final Questions and Acknowledgments
What bothers you most about your hair loss?
*
What are you hoping treatment will improve?
*
Anything else you would like the clinician to know?
Acknowledgments
*
Completing this assessment does not guarantee oral minoxidil will be prescribed
The clinician may recommend additional evaluation, testing, photos, an in-person examination, or another specialist before treatment
The information I provided is accurate and complete
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