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Hair Loss - Clinical Assessment

If you have previously used this service, you can log in here to complete the questionnaire more quickly. Our pharmacist team will review your answers and, where appropriate and in line with the service criteria, medicines may be supplied.

About You

Are you registered with a GP practice in the UK?

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Do you give us consent to notify your GP of the supply and to share information we hold about you?
(The information entered below in the clinical assessment form will be treated with utmost confidentiality whilst being reviewed by our clinical team. It will also provide our clinical team with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

 

Do you believe you have the capacity to make decisions about your own healthcare?

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Are you male and aged between 18 - 65?

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Symptoms

Are you suffering from hair loss?

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Do you have hair loss in patches, or have an itchy or sore scalp?

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Is your hair loss limited to the temple area?

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Are you experiencing any inflammation on your scalp?

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Do you have sudden unexplained hair loss or complete hair loss?

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Could your hair loss be explained by any medication or illness (e.g. chemotherapy or dietary)?

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Health

Are you allergic (hypersensitive) to Propecia (finasteride)?

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You must answer the question to continue.
 

Have you ever been diagnosed with prostate disease or male breast cancer or undergoing PSA (prostate monitoring)?

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Do you have a history of depression or any other mental illness?

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Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

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Are you taking any of the following medications?

  • Finasteride, Propecia or Proscar for a condition other than hair loss

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Agreement

Do you understand that if your partner is (or may be) pregnant, they should not handle crushed or broken tablets of finasteride, and that you should always wear a condom for sex?

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Do you understand that Propecia may take up to 6 months before symptoms start to improve?

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Some trials have suggested finasteride use may very slightly increase the risk of developing male breast cancer and prostate cancer. Do you agree to speak immediately to your doctor if:

  • You experience any changes in breast tissue such as pain, lumps or discharge from a nipple
  • You experience any pain, impotence, problems with ejaculation or loss of libido
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Are you aware that Propecia may cause erectile dysfunction and you should speak to your GP if this happens?

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Do you understand you must stop taking Propecia/Finasteride immediately if you experience any mood alteration including depressed mood, depression or suicidal ideation and should contact a healthcare professional?

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Do you agree to the following?

  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use
  • You have answered all of the above questions accurately and truthfully. You understand that our clinical team will review your answers and make decisions based on the information you provide, and that providing incorrect information may be unsafe and could affect your treatment.
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