Do you have any known drug allergies?
Yes
No
choose
If yes, please list in the box provided:
Do you use tobacco products?
Yes
no
choose
If yes, please quantify type of product and usage:
Do you consume alcohol?
No
Yes
choose
If yes, please quantify type of product and usage:
Do you currently follow a routine exercise program?
Yes
No
choose
If yes, please quantify type and amount of exercise:
Yes
No
choose
If yes, please list:
Do you have any of the following medical conditions?
Medical Definitions
Do you have any of the above medical conditions?
Yes
No
choose
If yes,
please explain:
Do you have a history of any other medical condition?
Yes
No
choose
If yes, please explain:
Have you had any surgeries in the past five (5) years?
Yes
No
choose
If yes please explain:
Yes
No
choose
If yes, please explain:
Was your hair loss gradual?
Yes
No
choose
If you answered yes, please explain and also include the age
you started losing hair:
Was your hair loss sudden?
Yes
No
choose
If you answered yes, please explain and also include the age
you started losing hair:
Does male pattern hair loss run in your family?
Yes
No
choose
If you answered yes, please explain:
Have you ever been treated for hair loss before?
Yes
No
choose
If you answered yes, please explain what type of treatment:
PropeciaŽ can effect a blood test called prostatic specific
antigen (PSA) for the screening of prostate cancer. It is very
important if you have a PSA test done, to inform your physician
that you are taking PropeciaŽ. Specifically, do you currently
plan to have a PSA blood test for the screening of prostatic
cancer in the near future?
Yes
No
choose
If you answered yes, please explain:
Note: There is no correlation between taking PropeciaŽ and
prostate cancer.
