Hair Loss
How quickly has your hair loss developed?
Gradually / Over months or years
Suddenly / Over days or weeks
Were you ill or had fever or underwent surgery under the past two weeks?
Yes
No
How much hair have you lost?
Some- those close to me notice it
A lot - it’s obvious to everyone
Where are you noticing hair loss?
Along the hairline
At the crown
All Over
Are you undergoing any hair loss treatment?
Yes
No
What hair loss treatments are you undergoing?
Shampoo or other OTC products
Topical Minoxidil / Regaine
Oral minoxidil
Oral Finasteride / Propecia
Do you take any other medications?
Yes
No
Please name the medications you are currently taking
Have you ever been diagnosed with?
None
Rheumatoid Arthritis Systemic Lupus or on Methotrexate
Scalp Disorders (including Scalp Psoriasis Eczema. Dermatitis or Infection)
Liver Disease or Abnormal Liver Function
Prostate Disease Male Breast Cancer or Testicular Cancer
High Blood Pressure
Significant Depression or Anxiety
Other Mental Health Disorders
Sexual Dysfunction
Cardiovascular Disease (inci Heart Attack Rhythm Valve Disorder or Stroke)
Other
Medical Condition
What type of treatment do you prefer? It may be considered depending on your hair loss stage
Oral - pills or tablets etc
Topical - foam or oils etc
Both or any
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