Questionnaire
Eligibility Check
1. How old are you?
2. What sex were you assigned at birth?
Hair Loss Pattern
3. Which of the following best describes your hair loss? (Select all that apply)
Extent of Baldness
4. Do you have complete baldness?
Scalp Condition Check
5. Do you currently have any of the following scalp problems? (Select all that apply)
Hair Loss Elsewhere
6. Have you lost hair anywhere else on your body?
Hair Loss Timeline
7. When did you first notice your hair loss?
8. How did your hair loss begin?
Current Medication
9. Are you currently using finasteride or Propecia for hair loss?
Pregnancy Safety
10. Is your partner currently pregnant or trying to get pregnant?
Please confirm:
Medications
11. Are you taking any medication for a prostate condition?
12. Are you taking any other prescription medicines, over-the-counter medicines, supplements, or recreational drugs?
Medical History
13. Do you have, or have you ever had, any of the following? (Select all that apply)
Allergies
14. Do you have any known allergies?
Understanding & Consent
15. Please confirm the following statement is true:
“You will need to take this treatment for at least 3–6 months before seeing any benefit, and stopping treatment will reverse any regrowth.”
16. Prostate blood tests
17. Important side effects
- Low mood or depression
- Sexual problems
- Breast tenderness or growth
If Side Effects Occur
18. If I experience side effects:
GP Notification
19. Would you like us to inform your GP about any care we provide?
Prescription Upload
If you have a prescription, you may upload it here (optional)
Prescription Upload
Or Drop files here to upload
Maximum upload file size: 5MB
Final Declaration
20. Please confirm: