Hair Loss Questionnaire – Prosper Healthcare

We hope to support you on your journey

We are going to ask some questions so we can assess whether we can help you.

This questionnaire is like a consultation. After completing the questionnaire, we will arrange a meeting with our practitioner to issue the appropriate treatment.

On average this questionnaire takes 4 minutes to complete.

If you prefer to book an appointment without filling the questionnaire, then no problem! Use our appointment booking service to speak to one of our clinicians.

Section 1 - Declaration

By proceeding and submitting the questionnaire, you confirm you:

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Check all five boxes to Proceed *

Are completing this questionnaire for yourself and to the best of your knowledge
Will disclose any medical conditions, serious illnesses or operations you have had
Will disclose any prescription medication you currently take
Are registered with a GP practice in the UK
Accept our Terms and Conditions

Section 2 - Information About You

Below are questions relating to your symptoms, previous diagnosis and to rule out anything else

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

When is your date of birth *

This service is only available if you are over 18

Email *

Phone

NHS Number

Have you previously been diagnosed with male pattern baldness? *

Yes
No
Maybe

There are seven levels of hair loss. Choose the degree of hair loss using Hamilton-Norwood scale: *

Norwood 1 — the man has a normal head of hair with no visible hair loss.
Norwood 2 — the hair is receding in a wedge-shaped pattern.
Norwood 3 — the man has the same receding pattern as Norwood 2, except the hairline has receded deeper into the frontal area and the temporal area.
Norwood 4 — the hairline has receded more dramatically in the frontal region and temporal areas than in Norwood 3, and there is the beginning of a bald spot at the back of the head.
Norwood 5 — the hair grows in the same pattern as Norwood 4 but with a much reduced hair density.
Norwood 6 — the strip of hair connecting the two sides of the head that existed in Norwood 4 and 5 no longer exists in Norwood 6.
Norwood 7 — the man has hair receding all the way back to the base of the head and the sides just above the ears.

Section 3 - Suitability of Treatment

Lets see if medication is suitable for you and get you the right treatment plan

Do you have any allergies or sensitivities? *

Please state your allergies or sensitivities *

Have you tried any of the following treatments? *

No treatment (in mild pattern hair loss).
Aesthetic options (such as hairpieces and wigs and the use of hair styling, colouring, and hairsprays to improve the cosmetic appearance).
Drug treatment (topical minoxidil or oral finasteride 1 mg tablets).
Surgical treatment (hair transplantation).
None

Are you aware of any liver or kidney problems? *

Yes, I have liver problems
Yes, I have kidney problems
I am unsure
None

Do you take any of the following medications? *

Aspirin and NSAID (ibuprofen, naproxen, diclofenac)
Oral contraception
Blood pressure medication
Erythromycin
Ritonavir
Recreational drugs
None of the above

Do you have any of the following which can affect hair loss? *

Recent severe infection
Endocrine disorder (hypothyroidism)
Family history of hair loss
Autoimmune response
Profound shedding or rapid onset of hair loss — may indicate telogen effluvium.
Temporal hair thinning — may indicate traction alopecia, frontal fibrosing alopecia, or hypothyroidism.
Absent or reduced eyebrows or eyelashes — may suggest a frontal fibrosing alopecia or alopecia areata.
Inflammation, papules or pustules, scaling, or scarring of the scalp — may suggest scarring alopecia.
Systemic disease, such as a recent severe infection, iron deficiency, or hypothyroidism.
Exposure to (or a change of) medication.
Change in dietary habits or rapid weight loss.
None of the above

Is the medication appropriate for you? Check all that apply.

Hypersensitivity to finasteride
Have severe liver disease
Have mild to moderate liver disease.
Have obstructive uropathy.
None of the above

You agree to the following:

If you have a female partner — the use of a condom is recommended if the partner is pregnant or likely to become pregnant.
No women who are pregnant or likely to become pregnant should not handle finasteride tablets, especially if crushed or broken, because of the possibility of absorption of finasteride and the subsequent potential risk to a male fetus (including abnormalities of the external genitalia).

Signature *