Hair Loss - Consultation

What is your name ?

What is your gender ?

Male

Female

What is your Dob ?

Select the image that looks most like your hair.

Which best describes your hair loss?

Receding hair line

Patches of thinning

Thinning at the temple

Thinning on the crown

Not sure

When did you first notice hair loss/thinning?

1 - 3 months

More than 3 months

How has hair loss progressed?

Gradual

Rapid

Do you have a family history (on either side) of male pattern baldness?

Yes

Not Sure

Have you got any redness or itching of the scalp?

Yes

Have you tried anything for hair loss before?

Yes

If you have tried treatment before, did you experience any side effects?

Yes

Do you currently have, or have had any of the following conditions

Are you currently undergoing an investigation for prostate issues/do you have raised PSA levels?

Yes

Have you been diagnosed with prostate cancer?

Yes

Some patients taking Finasteride or Dutasteride have reported depression and, rarely, suicidal thoughts. Do you suffer from or have a history of:

Depression

Suicidal thoughts

Suicide attempts

None of the above

How often have you had little interest or pleasure in doing things?

How often have you felt down, depressed or hopeless?

Are you under the care of your GP for any conditions?

Yes

Do you take any medications, prescribed or bought over the counter?

Yes

Do you have any allergies?

Yes

Are you happy for our prescriber to access your Summary Care Records?

Yes

To support safe prescribing please provide your GP details.

Yes

We strongly recommend informing your GP of any treatment received. Would you like us to notify your GP on your behalf?

Yes

I understand that

Finasteride works gradually and it will be 3 - 6 months before I notice any beneficial changes

Results may vary between individuals

Treatment is long term and stopping treatment will lead to regression

Side effects are uncommon but must be discussed with your GP at the earliest opportunity

I should inform my GP of any new treatment I start so that my medical records can be updated

I must read the patient Information leaflet supplied with my medication

I must ensure that no women of child bearing age will handle the tablets and I must wear condoms during sexual intercourse

Is there anything else that you would like our specialist to know?

The decision to prescribe rests solely with the prescriber.

I confirm that I understand and agree to the above