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Hair Loss

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. Are you purchasing this medication for yourself?
2. Are you over 18 years old?

Medical History

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

Please let us know if you have any of the following:

profound shedding or a rapid onset of hair loss on the scalp or other areas of the body
Recent severe infection, iron deficiency, hypothyroidism, systemic lupus erythematosus, or cancer.
Exposure to or a change of medication (for example antidepressants, anticoagulants, and chemotherapy, anabolic steroids, carbimazole)
Patchy hair loss of the scalp and eyebrows.
suffer from treated or untreated high blood pressure, arrythmia or any other cardiovascular dis-ease
suffer from Phaeochromocytoma
suffer from any current scalp issues including but not limited to infection, psoriasis, eczema, sun-burn, broken skin or unspecified scalp pain, irritation, or inflammation
have a shaved scalp
have a condition where you use occlusive dressings.
None of the above

5. Do you currently take any treatment for benign prostate hyperplasia (such as finasteride, tamsulosin, alfuzosin, doxazosin)?

Past Medical History

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

Please provide more details:

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

Please provide more details:

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

Please provide more details:

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

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

11. 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.

  • You have read the information available on the treatments and medication 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.
  • 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.

I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet

Please click "Yes".