Hair Loss Assessment

09/06/2023 02/12/2025

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at enquiries@thefamilychemist.co.uk

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

STOP. This consultation must be filled in by the male patient.

Yes No

3. Are you male and over 18 years old?

The Family Chemist does not supply hair loss medication to female patients or under 18s. Stop and see your GP.

Yes No

Medical History

4. Do you currently have or suffer with male pattern baldness?

STOP! You must have or suffer from male pattern baldness or hair loss before proceeding with this consultation.

Yes No

6. Do you currently take any treatment for hair loss?

Yes No

6b. What treatment are you currently using or used?

7. Do you currently take any treatment for an overactive bladder or enlarged prostate (such as finasteride, dutasteride, tamsulosin, alfuzosin, doxazosin)?

Yes No

7b. What medication are you using for an overactive bladder or enlarged prostates?

8. Do you suffer from any of the following:

None

Fast, irregular heart beat or angina

Chest pains or shortness of breath

Low blood pressure leading to dizziness and/or fainting.

Phaeocromocytoma

Pulmonary hypertension with mitral stenosis

Angina

Recent heart attack

Left ventricular hypertrophy or heart failure

9. Are you ordering Minoxidil or taking Minoxidil?

Yes No

9b. Are you currently taking any medication for:

None

Blood pressure.

Heart Failure.

Vascular System (Blood vessels)

Erectile Dysfunction

Any other medication that can lower your blood pressure.

Past Medical History

10. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Yes No

10b. Please provide more details:

11. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Yes No

11b. Please provide more details:

12. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Yes No

12b. Please provide more details:

13. Do you have a hereditary intolerance to galactose, lapp lactase deficiency or glucose-galactose malabsorption?

Yes No

13b. Please provide more details:

14. Would you like us to pass on details of your treatment to your GP?

Yes No

14b. Please provide more details:

Please Provide GP Email (preferred):

Unable to find your surgery? Click Here

15. Do you understand the following:

I will stop using Finasteride or Dutasteride if:

I notice any changes in my mood or well-being, such as feeling low or experiencing changes in my sexual function (including decreased sex drive and inability to get and maintain an erection).

Yes No

16. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at enquiries@thefamilychemist.co.uk so we can talk through your options.

IMPORTANT: PLEASE READ

For Avodart, Dutasteride and Minoxidil Patients:

Dutasteride and Minoxidil is prescribed off-label for hair loss. Please ensure you have read the patient information leaflet for Dutasteride or Minoxidil and the FAQs on the Dutasteride and Minoxidil product page before ordering the medication.
Minoxidil can cause a significant retention of salt and water leading to swelling (oedema) and clinical deterioration of some patients with heart failure. You must have your body weight, fluid and electrolyte balance monitored by your GP.

For All Patients:

I understand I need to ask my doctor to do a prostate specific antigen (PSA) test every 6-12 months whilst take finasteride, avodart or dutasteride.
Woman who are pregnant or planning to become pregnant should not touch crushed or broken finasteride tablets or dutasteride capsules. Stop using dutasteride, avodart or finasteride if you are trying for a baby in the next 12 weeks.
Finasteride and dutasteride may lower sperm counts and cause temporary infertility in some men. Couples having difficulty conceiving need to be aware of the possibility of a lower sperm count due to long term use of finasteride or dutasteride.
You must report any lumps, pain, or growth in your chest tissue and any problems urinating to your GP.

You have read the information available on the treatments and medication (Finasteride, Dutasteride) web page and understand the side effects, their effectiveness and alternatives available.
You have answered the questions honestly and accurately and the treatment is solely for your personal use.
You will read and understand the patient information leaflet supplied with your medication. Propecia. Finasteride. Dutasteride. Regaine, Avodart, Minoxidil.
You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
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 are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes No

17. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Hair Loss Assessment

About You

Medical History

Past Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

Unit 1, Wilford Business Park,
Ruddington Lane,
Nottingham,
NG11 7EP

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About You

Medical History

Past Medical History

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