Hair Loss

Are you male at birth aged between 18 to 41 years old? *

Please select the pattern of your hair loss according to the chart below. *

Which of the following best describes your hair loss? (Tick all that apply) *

Are you experiencing sudden or gradual hair loss? *

Shedding is defined as having excessive numbers of hairs falling out daily. Do you feel that you have been shedding excessive numbers of hairs (in the shower, on your hair brush, etc)? *

Thinning is defined as having less hair to cover the scalp, with or without excessive hairs lost each day. Do you feel that your scalp hair is slowly thinning out over the top without losing excessive numbers of hairs daily or changes in hair texture? *

Have you noticed any of the following skin conditions on scalp? *

• Psoriasis, fungal infections such as ringworm, or dandruff of your scalp
• Infection or broken skin
• Eczema
• Redness, rough or scaling of the scalp
• Any blistering or pus-filled spots on the scalp

Do you have symptoms on the scalp? *

• Itching
• Tenderness
• Pain
• Burning
• Dandruff
• Irritation
• Inflammation

Within 6 months PRIOR to the onset of hair loss, have you: *

• Started on any new medication
• Experienced any significant medical issues in your life, such as surgery, illness or hospitalization
• Experienced any significant stress, such as divorce, family illness/bereavement or work issues
• Any recent weight loss or change in diet

Have you used any hair loss medications in the past? Were they helpful? *

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? *

Do you have any allergies? Have you had an allergic reaction or adverse response to finasteride or its excipients? *

Have you ever been diagnosed with one of the following conditions: *

• Heart Disease (including chest pain, angina, heart attack or any history of cardiovascular event)
• Pheochromocytoma (cancer of the adrenal glands)
• Male breast cancer
• Acute Porphyria (a rare hereditary disease affecting haemoglobin)
• Prostate problems (prostate enlargement, prostatitis, prostate cancer)
• Depression, anxiety or low mood
• Liver problem
• Hereditary problems of galactose intolerance, Lapp lactase deficiency or glucosegalactose malabsorption
• Kidney problem
• Sexual dysfunction (including decreased sex drive and erectile dysfunction)
• Anemia
• Thyroid disorders

Do you have any other health problems or conditions that you think we should know about? e.g. G6PD, mental illness, neurological conditions etc. *

Are you using any medicines, creams or dressings for your scalp? *

Are you taking medication for a prostate condition? *

Is your partner pregnant or trying to get pregnant? *

Are you aware that some people have experienced depression while taking this medication and that can last even when medication is stopped. If this happens you agree to stop taking this treatment and speak to your own doctor straight away *

Can you please confirm that if your partner is pregnant, she should not handle crushed or broken tablets of Finasteride and that you should always wear a condom for sex? *

In some trials of finasteride, it has been suggested that there is very slight increase in the risk of developing male breast cancer and prostate cancer. Please confirm that you will speak immediately to your doctor if: *

• You experience any changes in breast tissue such as pain, lumps or discharge from a nipple
• You experience any pain, impotence, problems with ejaculation or loss of libido

Please confirm that you understand these medicines may affect prostate-specific antigen (PSA) blood test results. If you require a PSA test, you should inform your doctor that you are taking finasteride (also known as Propecia). A baseline PSA test is recommended before starting treatment, and it is mandatory for men over the age of 40. If you have had a PSA test, please provide the result, if known. *

Can you please confirm that you understand it can take up to 6 months of using Finasteride before you see any benefit, and stopping treatment will reverse any regrowth and hair loss will resume. *

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 contact your regular prescriber if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records. *

To ensure your medication is prescribed safely, our clinical team may need to: *

• Access your medical records (including your Summary Care Record, where applicable)
• Invite you to take part in a follow-up phone or video consultation for further clarification

Do you agree to the following? *

• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
• You will inform your doctor about any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
• You will not exceed the maximum daily dose of this medication
• You confirm you have the capacity to make decisions about my own health