Consultation - Pharmaceutra

Hair Loss

Hair loss is a common condition that can affect people of any gender and age. It may develop gradually or occur suddenly, depending on the underlying cause. Some people experience general hair thinning, while others notice a receding hairline, thinning around the crown, or patchy hair loss. Hair loss can be caused by genetics, hormonal changes, stress, nutritional deficiencies, medical conditions, or certain medications.

Although some types of hair loss are temporary, others may be long-lasting or progressive. Hair thinning and hair loss can affect confidence and self-esteem, but several treatment options are available to help manage hair loss, support hair growth, and improve hair density, depending on the cause.

Please complete the form below so that our clinicians can assess your hair loss and determine whether the treatment is suitable for you.

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.

What is your date of birth?

What is your gender?

Female

Male

Do you have any known allergies?

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

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

Are you currently taking any medications?

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

Have you had any surgeries in the past year?

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

Do you smoke?

Do you consume alcohol?

If yes, how much a day/weekly?

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

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.

How long have you been experiencing hair loss?

Please provide more detail here

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

Yes

If yes, please provide more detail here

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

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

Please provide more detail here

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

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

Have you been prescribed medication for hair loss before?

Are you currently taking any medication for hair loss?

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

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

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.

Understanding of Risks

Yes

Medical Guidance

Yes

Consent to Share Information

Yes

Confirmation

Yes

Consent to SCR (Service Care Record)

Yes

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

Acid Reflux

Acne

Anxiety

Asthma

Contraception

Eczema

Erectile Dysfunction

General Health & Antibiotics

Hair Loss

HRT

Malaria Prevention

Period Delay

Premature Ejaculation

UTI

Weight Loss

Assessment for Hair Loss

Hair Loss

1 About Your Health

What is your date of birth?

What is your gender?

Do you have any known allergies?

Yes

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

Yes

Are you currently taking any medications?

Yes

Have you had any surgeries in the past year?

Yes

Do you smoke?

Yes

Do you consume alcohol?

Yes

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

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

2 About Your Condition

How long have you been experiencing hair loss?

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

Yes

Yes

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

Yes

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

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

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

Yes

Have you been prescribed medication for hair loss before?

Yes

Are you currently taking any medication for hair loss?

Yes

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

Yes

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

Yes

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

Yes

3 The Agreement and Consent

Understanding of Risks

Medical Guidance

Consent to Share Information

Confirmation

Consent to SCR (Service Care Record)

Assessment Progress

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