What results are you looking for?
Grow more hair
Get healthy hair
Both
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Are you male or female?
Female
or
Male
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Are you taking any form of birth control?
Yes
or
No
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Do you have the ability to become pregnant?
Yes
or
No
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When did you first notice hair loss or hair thinning?
Not started yet, I want to prevent it
Within the last month
Over the last 6 months
Over a year
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On what areas are experiencing hair loss or hair thinning?
Select that apply
No hair loss yet
Hairline (front)
Crown (top of scalp/vertex)
Along my part
Diffuse across my scalp
Facial hair
Eyebrows/lashes
Other
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Have you ever had hair loss evaluated by a physician?
Yes
or
No
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If yes, have you ever been diagnosed with any of the following hair loss conditions?
Select that apply
Androgenetic Alopecia
Alopecia Areata
Traction Alopecia
Telogen Effluvium
Lupus or other Autoimmune Condition
Inflammatory/Scarring Alopecia
Scalp Psoriasis/Severe Dandruff
Nutritional Deficiency
Thyroid Disorder
Other
I don’t remember
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Do you have any of the following symptoms in addition to your hair loss?
Select that apply
Itching, burning, redness, and/or scalp tenderness
Bumps, pustules, sores or rashes on your scalp
Hair loss started during or after a major medical or life event
Sudden high volume of hair loss/shedding
Smooth round patches of hair loss
Thin band of hair loss along frontal scalp
Hair loss on other parts of my body like eyelashes/eyebrows
Regularly wear my hair in ways that can stress my hair/scalp
Other
I don’t remember
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Are you currently on or have you previously tried any hair loss treatments?
Yes
or
No
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Which treatments have you tried?
Select that apply
Rogaine
Oral Minoxidil
Oral Finasteride 1mg (Propecia)
Oral Finasteride 5mg (Proscar)
Topical Finasteride
Oral Dutasteride (Avodart, Jalyn)
Topical Dutasteride
Oral Spironolactone
Topical Spironolactone
Other
No prior treatments tried
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Did you experience any side effects from these treatments?
Yes
or
No
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Will you continue to use these treatments?
Your prescribing doctor needs to know everything you intend to use for hair loss to ensure the combination of therapies are safe for you.
Yes
or
No
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Do you have any issues with sexual dysfunction currently?
Yes
or
No
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Are you or your partner currently pregnant, breastfeeding, or planning to get pregnant in the next 6 months?
Yes
or
No
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Do you currently have or have you had any history of mental health conditions?
Yes
or
No
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How long ago was your most recent check up with a physician?
Within past year
Within 2 years
Within 3-5 years
Over 5 years
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Do you have any more questions or anything else you would like your doctor to know?
This includes weight, blood pressure, and heart rate
Yes
or
No
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Please acknowledge that you understand and agree to the following
I have filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me.
I understand all the questions that have been asked of me.
The information that I have provided is accurate and complete.
I am the patient who is consenting to be evaluated for treatment via telehealth.
I don’t remember
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