Hair Loss Assessment | Pharma Aesthetics

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Hair Loss Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Hair Loss Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Have you noticed a significant increase in hair shedding when brushing or washing your hair?*

Yes

No

Please provide more information below.*

Do you observe thinning hair or bald patches on your scalp?*

Yes

No

Please provide more information below.*

Has the texture of your hair changed, becoming finer or more brittle?*

Yes

No

Please provide more information below.*

Is the hair loss localized to specific areas or more general across the scalp?*

Yes

No

Please provide more information below.*

Have you experienced any itching, burning, or irritation on your scalp associated with hair loss?*

Yes

No

Please provide more information below.*

Health

Are you currently undergoing any form of medical treatment or taking medication that could potentially contribute to hair loss, such as chemotherapy or thyroid medications?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any underlying health conditions, such as thyroid disease, anaemia, or autoimmune diseases, that might be linked to hair loss?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you had any recent significant stressors or life changes that could have triggered the onset or worsening of hair loss?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you following a balanced diet, or have you been diagnosed with nutritional deficiencies that could affect hair health, like low levels of iron or vitamin D?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you previously sought treatment for hair loss, and if so, what treatments were tried?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to provide a comprehensive understanding of the patient's condition and any contributing factors, which is crucial for the safe and effective prescription of hair loss treatments.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Name

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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