Consultation - Chemist 69

Hair Loss

Male pattern baldness is a common, genetic condition that leads to permanent hair loss. Male pattern baldness affects 50% of men over 50 years of age but can also affect men in their 20s. The hair loss in male pattern baldness starts as a thinning of the hair at the sides and on the top of the head. So it’s this “pattern” that defines the condition and separates it from other types of hair loss. While this form of hair loss in men isn’t serious and doesn’t need treatment, it is permanent and can be distressing. The loss of hair can affect your confidence and self-esteem. However, there are several treatment options available to stop your hair loss and even regrow new hair.

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Question 1:What is your date of birth?

Question 2:What is your gender?

Female

Male

Question 3:Do you have any known allergies?

Question 4:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Question 5:Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Question 6:Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Question 7:Do you smoke?

Question 8:Do you consume alcohol?

If yes, how much a day/weekly?

Question 9:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Question 10:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Question 1:How long have you been experiencing hair loss?

Please provide more detail here

Question 2:Have you been diagnosed with a specific type of hair loss by a healthcare professional?

Yes

If yes, please provide more detail here

Question 3:Have you had any tests to confirm the diagnosis? (e.g., blood tests, scalp biopsy)

Question 4:What symptoms are you currently experiencing? (e.g., thinning hair, bald patches, receding hairline)

Please provide more detail here

Question 5:How quickly has your hair loss progressed? (e.g., sudden, gradual)

Question 6:Are there specific triggers that worsen your symptoms? (e.g., stress, certain hair products)

Question 7:Have you been prescribed medication for hair loss before?

Question 8:Are you currently taking any medication for hair loss?

Question 9:Have you experienced any side effects from your current or past hair loss medications?

Question 10:Have you tried any non-medication treatments for hair loss? (e.g., dietary changes, scalp massages, laser therapy)

Question 11:Have you used over-the-counter treatments for hair loss?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Question 1:Understanding of Risks

Yes

Question 2:Medical Guidance

Yes

Question 3:Consent to Share Information

Yes

Question 4:Confirmation

Yes

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

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Assessment for Hair Loss

Hair Loss

1 About Your Health

Question 1:What is your date of birth?

Question 2:What is your gender?

Question 3:Do you have any known allergies?

Yes

Question 4:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Question 5:Are you currently taking any medications?

Yes

Question 6:Have you had any surgeries in the past year?

Yes

Question 7:Do you smoke?

Yes

Question 8:Do you consume alcohol?

Yes

Question 9:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Yes

Question 10:How often do you exercise? (e.g., daily, weekly, rarely, never)

Yes

2 About Your Condition

Question 1:How long have you been experiencing hair loss?

Question 2:Have you been diagnosed with a specific type of hair loss by a healthcare professional?

Yes

Yes

Question 3:Have you had any tests to confirm the diagnosis? (e.g., blood tests, scalp biopsy)

Yes

Question 4:What symptoms are you currently experiencing? (e.g., thinning hair, bald patches, receding hairline)

Question 5:How quickly has your hair loss progressed? (e.g., sudden, gradual)

Question 6:Are there specific triggers that worsen your symptoms? (e.g., stress, certain hair products)

Yes

Question 7:Have you been prescribed medication for hair loss before?

Yes

Question 8:Are you currently taking any medication for hair loss?

Yes

Question 9:Have you experienced any side effects from your current or past hair loss medications?

Yes

Question 10:Have you tried any non-medication treatments for hair loss? (e.g., dietary changes, scalp massages, laser therapy)

Yes

Question 11:Have you used over-the-counter treatments for hair loss?

Yes

3 The Agreement and Consent

Question 1:Understanding of Risks

Question 2:Medical Guidance

Question 3:Consent to Share Information

Question 4:Confirmation

Assessment Progress

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