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Medical Assessment for Hair Loss

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You
Are you male and aged between 18-65?
    This treatment is not suitable for women, or those under 18 or over 65.
    Please complete this question.
    Have you been taking Finasteride for more than 3 months?
    Please complete this question.
    Have you noticed any visible reduction in hair loss since you began taking Finasteride?
    Although Finasteride starts working immediately, it can take up to six months to see the benefits of Finasteride.
    Please complete this question.
    Have you experienced any sexual side effects (e.g. erectile dysfunction, low libido, ejaculation disorders) since starting to take finasteride?
    Please complete this question.
    Certain studies have shown a possible link between Finasteride or Propecia leading to erectile dysfunction or a low sperm count and semen volume. If these side effects occur, they are usually reversible when the medication is stopped, however in rare cases they may be permanent. With this in mind, are you happy to continue with Finasteride?
      We will still be able to offer you treatment, but with a limited range.
      Please complete this question.
      Have you experienced any psychological side effects (e.g. depression, suicidal thoughts) since starting to take finasteride?
        We may still be able to offer you hair loss treatment, but with a limited medicine range after completing the consultation. We recommend consulting NHS services for advice on depression.
        Please complete this question.
        Your Symptoms
        Have you noticed thinning of your hair at the sides, front and/or the top of the scalp?
          We are unable to supply you with treatment if you have not noticed any thinning of your hair. Please consult your GP or doctor for more information.
          Please complete this question.
          Could your hair loss be explained by any medication, dietary matter or illness?
            If a lifestyle or health factor is causing your hair loss, we recommend speaking to your GP or doctor for further advice.
            Please complete this question.
            Do you have a healthy scalp?
            • no inflammation on the scalp
            • no redness
            • no medical dressings
            We are unable to supply you with treatment. Please consult your GP or doctor.
            Please complete this question.
            Do you have hair loss in patches, or have an itchy or sore scalp?
              This treatment is not suitable for you. We recommend contacting your GP or doctor for further advice.
              Please complete this question.
              Do you have sudden unexplained hair loss or complete hair loss?
                This treatment isn't suitable for this type of hair loss. We recommend you speak to your GP or doctor for further advice.
                Please complete this question.
                Your Health
                Are you allergic to any of the following? (Tick all that apply)
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                Please complete this question.
                Do you have a history of depression, suicidal thoughts and/or any other mental illness?
                We will still be able to offer you treatment, but with a limited product range. We recommend consulting NHS services for advice on depression.
                Please complete this question.
                Have you ever been diagnosed with or treated for any of the following conditions? (Tick all that apply)
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                Please complete this question.
                Your Medication
                Are you currently taking any medication (over-the-counter or prescription) or any recreational drugs?
                Please complete this question.
                Are you taking any of the following medications? (Tick all that apply)
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                We may still be able to offer you hair loss treatment, but with a limited medicine range.
                Please complete this question.
                Please complete this question.
                Please complete this question.
                Agreement
                Do you understand that if you are prescribed finasteride and your partner is (or may be) pregnant, they should not handle crushed or broken tablets, and that you should always wear a condom during sex?
                  We are unable to supply you with treatment unless you understand and agree to this point.
                  Please complete this question.
                  Do you understand that if you are prescribed finasteride, you should inform your GP of this before undergoing a PSA blood test for your prostate?
                    We are unable to supply you with treatment unless you understand and agree to this point.
                    Please complete this question.
                    Do you understand that if you and/or your partner are planning to conceive, we recommend temporarily stopping treatment with finasteride?
                      We are unable to supply you with treatment unless you understand and agree to this point.
                      Please complete this question.
                      Do you understand that you should stop finasteride and seek medical attention if you have any changes in your breast tissue such as lumps, pain or nipple discharge?
                        We are unable to supply you with treatment unless you understand and agree to this point.
                        Please complete this question.
                        Do you understand that finasteride is associated with low mood, depression, suicidal thoughts and sexual dysfunction (decreased sex drive, erectile dysfunction and ejaculation disorders)?
                          We are unable to supply you with treatment unless you understand and agree to this point.
                          Please complete this question.
                          Do you understand that before taking finasteride, you should read and keep the Finasteride patient cards and patient information leaflet within your pack and inform Pharmica if you have any personal history of depression or suicidal thoughts?
                            We are unable to supply you with treatment unless you understand and agree to this point.
                            Please complete this question.
                            Do you understand that if you have seriously harmed yourself or feel you are at risk of serious harm, contact emergency services on 999 immediately?
                              We are unable to supply you with treatment unless you understand and agree to this point.
                              Please complete this question.
                              Do you understand that you should stop finasteride 1mg immediately if you develop depression or suicidal thoughts and contact your doctor as soon as possible?
                                We are unable to supply you with treatment unless you understand and agree to this point.
                                Please complete this question.
                                Do you understand that if prescribed finasteride and you experience decreased sex drive, difficulty having an erection or ejaculation problems you should contact your doctor for medical advice?
                                  We are unable to supply you with treatment unless you understand and agree to this point.
                                  Please complete this question.
                                  Do you understand that taking finasteride can cause side effects like decreased sex drive and erectile dysfunction which may continue after treatment is stopped?
                                    We are unable to supply you with treatment unless you understand and agree to this point.
                                    Please complete this question.
                                    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, you start new medication and/or your medical conditions change during treatment
                                    • The treatment is solely for your own use
                                    • You have answered all the above questions accurately and truthfully
                                    • You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
                                    • You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber
                                    • You are capable and have the ability to make your own decisions about your healthcare.
                                    You must agree to this before continuing. If you need assistance contact our customer support.
                                    Please complete this question.
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                                    Ana Carolina Osorio De Faria Goncalves

                                    Ana Carolina Goncalves

                                    Superintendent Pharmacist

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                                    Need help?

                                    If you need help with this medical assessment, contact our helpline:

                                    0207 112 9014

                                    or email us

                                    help@pharmica.co.uk

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                                    We are regulated by the General Pharmaceutical Council

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