Finasteride Assessment FormNeil2021-01-08T11:49:36+00:00 Finasteride Assessment Name* First Last Date of Birth* DD slash MM slash YYYY Mobile Phone*Address* Street Address Address Line 2 City County Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Which of these pictures reflects your hairloss best?*--NAIIIIIIIIIvertexIVVVIVIIWhen did you first notice you were losing your hair?*--Less than 1 month ago1-6 months agoMore than 6 months agoHow did your hairless begin?*--Gradually over many months or yearsSuddenlyHave you ever taken Propecia or Finasteride?* Yes No NA Are you currently taking any medication, or have you recently finished a course of medication?* Yes No Details of Medication*Do you suffer from any problems with your kidneys, your urinary system or with your liver?* Yes No NA Have you ever been diagnosed with cancer of the prostate?* Yes No NA Do you have hair loss in patches, or have an itchy or sore scalp?* Yes No Do you have sudden unexplained hair loss, or complete hair loss, or hair loss caused by medication?* Yes No Are you aware that Propecia tablets / finasteride 1mg / finasteride 5mg are for men or post-menopausal womenonly?* Yes No NA Do you have any other health problems or conditions that you think we should know about? (e.g. mental illness, depression, anxiety, neurological conditions, recent or major operations, G6PD, etc.)* Yes No Health Problem Details*Communication between doctors involved in your treatment helps provide the safest and most effective healthcare. Would you like us to inform your GP about this treatment?* Yes No I consent for this information to be shared with my prescribing surgeon and his clinical providers* Yes No GP Details*Terms & Conditions* Please confirm that the following apply: I am over 18 The tablets are for my own personal use I will read the Patient information leaflet supplied with the tablets and follow the prescriber's instructions I confirm that I have read, understood and accept all information in the documents attached to the email sent to me and described at https://www.medicines.org.uk/emc/medicine/3679 regarding the side effects that may be experienced whilst taking Finasteride/Propecia. Â
