Kindly ascertain that the intended user is between the ages of 18 and 65.
Do you require assistance?

Yes

No

Are you currently receiving any treatment or using any medication?

Please provide more information of the medication being used if any.

Yes

No

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Are you aware of the following?
It has been proven that taking more than the suggested amount of a hair loss therapy does not boost its effectiveness.
If your spouse is pregnant or could become pregnant, you should use a condom during any sexual activity and don't let them handle hair loss therapy.
If you need a PSA blood test, notify your doctor that you are taking hair loss treatment because it may impact the findings.
If you have any unusual side effects while taking finasteride or dutasteride, you should consult your doctor. These include breast tissue changes such as lumps, larger breasts, discomfort or nipple discharge, a decreased libido, erectile dysfunction, and ejaculation disorders, as well as a decreased libido, erectile dysfunction, and ejaculation disorders.

Yes

No

If you have, how successful was it?

Have you been using dutasteride (Avodart) 0.5mg capsules to cure hair loss?

Yes

No

Can you relate to any of the following medication?
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.
Do you require assistance?

Yes

No

Are you getting treated or tested for the following conditions:
changes in your breast tissue, such as lumps, larger breasts, soreness, or nipple discharge melancholy, anxiety, or low mood
If you answered yes, please include as much information as possible, including any medications you are taking.
Do you require assistance?

Yes

No

For which duration have you had male pattern baldness?
Please select one option
A period of 0 to 3 months
3 - 12 months
Years 1 to 3
three years or longer

A period of 0 to 3 months

3 - 12 months

Years 1 to 3

Three years or longer

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.

Yes

No

Have you been using Finasteride tablet to cure hair loss?

Yes

No

How frequently do you monitor your blood prssure? Do you frequently visit your doctor?

Yes

No

Has a certified medical practitioner ever informed you of how high or how low your blood pressure is?
It could either be your personal doctor, another certified medical practitioner or through home self-test kits

Yes

No

Have you been using Regaine tablet to cure hair loss?
If so, for how long have you used it and how successful was it?

Yes

No

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.

Yes

No

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?

Yes

No

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.

Yes

No

Have you been using Propecia tablet to cure hair loss?
If so, for how long have you used it and how successful was it?

Yes

No

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.

Yes

No

Do you conscent to stop the consumtion of Finasteride immediately and seek medical help if you experience any of the following symptoms:
A depressed mood, despair, or suicidal thoughts
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.

Yes

No

Have you been using Finasteride 1mg pills (Propecia)
If so, how successful was it?

Yes

No

Have experienced any side effects with Finasterid before?
If yes, please proivide as much detail as possible.

Yes

No

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

Yes

No

How long have you been suffering with male pattern baldness?
Please indicate in months/years

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?

Yes

No

Do you realize that this medication is being prescribed 'off-label'?
Using the extra information option, you can learn more about off-label medicines.
Do you require assistance?

Yes

No

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

Is the progression of your hair loss symmetrical (the same on the right as on the left side of your scalp)?

Yes

No

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

Yes

No

Is your hair loss in clumps/patches, or is the hair loss rapid?

Yes

No

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 have any problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption?

Yes

No

Do you have any chronic medical conditions (e.g. cancer)?
If yes, please provide details

Please provide details in this box here...

Yes

No

Do you have any allergies?
If yes, please provide details

Yes

No

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?

Yes

No

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

Yes

No

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

Yes

No

Do you have depression, generalized anxiety disorder, psychosis, schizophrenia, or any other psychiatric disorder?

Yes

No

Do you have a history of depression, generalized anxiety disorder or any other psychiatric disorder?

Yes

No

Do you suffer from bladder obstruction (obstructive uropathy)?

Yes

No

Do you have any liver problems (hepatic impairment)?

Yes

No

Are you aware that crushed or broken tablets of finasteride should not be handled by women when they are or may potentially be pregnant?

Yes

No

Are you aware that you should tell your doctor you are receiving treatment before having a prostate-specific antigen (PSA) test?

Yes

No

Please list all your current prescription medication including any medication you buy over the counter...

Ear Health

Weight Management

Male Health

All Conditions

Hair Loss

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Ear Health

Weight Management

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All Conditions

Hair Loss

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