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Questions Related to Hairloss

In order to prescribe treatments for Hairloss our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

Please confirm the reason for wanting Hairloss treatment.

Where on your head are you losing hair? E.g. front, sides, crown etc.

How long have you been suffering with hair loss?

Please confirm you understand that pregnant or potentially pregnant women should not handle this medication directly.

Please confirm you understand that whilst using Propecia you should not have unprotected sexual intercourse.

Please confirm you understand that if you are planning to try for a baby over the next 6 months you should stop taking Propecia.

Are you suffering from complete or sudden hair loss (over a period of days or a few weeks), or hair loss caused by medication?

Yes No

Do you suffer from an illness or skin condition that might explain hair loss such as psoriasis or ring worm (fungal infection)?

Yes No

Please provide details.

Do you suffer from prostate cancer or an enlarged prostate?

Yes No

How long have you been suffering from this condition and what treatments are you taking?

Do you have any skin diseases?

Yes No

Please provide details.

I understand that these tablets can ONLY be taken by men.

Do you suffer with depression or suicidal thoughts?

Yes No

Provide details

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© 2014 Professional medical advice available on treatments and conditions that Firstmed prescribes for. FirstMed Consulting is one of the United Kingdom's most trusted online Medical Healthcare Providers providing medical consultation and prescription medicines to people who wish to avoid the embarrassment of a physical examination with their own doctor. Our team of healthcare professionals consists of EU registered doctors and UK registered pharmacists who are committed to the highest standards of care.