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Hair Loss Assessment

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 [email protected]

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.

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.

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.

5. Please let us know if you have any of the following RED flags:

Read FAQs before selecting any of the below.

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

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)?

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

8. Do you suffer from any of the following:

9. Are you ordering Minoxidil or taking Minoxidil?

9b. Are you currently taking any medication for:

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

10b. Please provide more details:

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

11b. Please provide more details:

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

12b. Please provide more details:

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

13b. Please provide more details:

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

15. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] 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.

16. 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.