Consultation Services from All Chemists | UK Based Pharmacy

Q No.	Question	Answer
1	Are you a male? You must answer this question. You must answer this question.	YesNo
2	Are you suffering from hair loss? You must answer this question. You must answer this question.	YesNo
3	Do you have hair loss in patches, or have an itchy or sore scalp? Irregular patchy hair loss needs investigation. You must answer this question. You must answer this question.	YesNo
4	Do you have sudden unexplained hair loss, or complete hair loss, or hair loss caused by medication? Hair falling out in clumps or over a period of days or weeks needs investigation. You must answer this question. You must answer this question.	YesNo
5	Are you suffering from an illness or skin condition that might explain hair loss? e.g. disease causing weight-loss or fevers e.g. skin conditions such as psoriasis or ringworm (fungal infection) You must answer this question. You must answer this question.	YesNo
6	Are you aware that Propecia tablets / finasteride 1mg are for men only? Propecia/finasteride 1mg will not work in women and may be harmful in pregnancy. Women should not handle crushed or broken tablets. You must answer this question. You must answer this question.	YesNo
7	Are you allergic to Finasteride? You must answer this question. You must answer this question.	YesNo
8	Are you already taking finasteride for a condition apart from hair loss, or taking dutasteride for prostate enlargement? Finasteride 5mg tablets (Proscar) are sometimes used to treat prostate enlargement. You must answer this question. You must answer this question.	YesNo
9	Are you ordering Regaine/minoxidil 5% and have significant low blood pressure or high blood pressure (even if controlled by tablets), or abnormal heart rhythm, or angina? Only significant if requesting Regaine/minoxidil 5%. If ordering Propecia/finasteride 1mg only please answer ‘No’. You must answer this question. You must answer this question.	YesNo
10	Are you aware there have been occasional reports of depression and even suicidal thoughts with Propecia/finasteride? If these occur, stop treatment immediately and consult a doctor. You must answer this question. You must answer this question.	YesNo
11	Are you aware finasteride can cause reduced libido and erection difficulty in about 1 in 100 men? If this occurs, stop taking finasteride and symptoms usually resolve. You must answer this question. You must answer this question.	YesNo
12	Are you aware that if hair loss has not reduced after 6 months, treatment should be stopped? You must answer this question. You must answer this question.	YesNo
13	Are you aware of the following? Propecia is excreted in semen and use of a condom is recommended if your partner is pregnant or likely to become pregnant Women of childbearing age should not handle crushed or damaged propecia tablets You must answer this question. You must answer this question.	YesNo
14	Do the following apply to you? The treatment is for my own use I will report any possible side effects I will read the patient information leaflet supplied in the medicine pack I am over 18 and I agree to identity verification checks I have completed this questionnaire myself and fully understand all the information My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment I agree to the terms & conditions, privacy policy, & data sharing policy You must answer this question. You must answer this question.	YesNo
15	What is the name of your GP surgery and do you consent to us contacting them about your treatment? You must answer this question. You must answer this question.

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