♂ Patient - Hair Loss Treatment

Page 1 of 2


Please identify the level of Male Pattern Baldness which you are currently experiencing?. *

For how long has your male pattern balding been an issue to you? *

Was your hair loss sudden or gradual? *

Have you noticed any itchy, rough or scaly patches on your scalp underneath your hair? *

Have you noticed any hair loss which has occurred on any other body locations (e.g. eye brows, genital or armpit areas)? *

Apart from conditions already mentioned in this form, do you suffer from any other medical conditions or have you had any surgical procedures in the past that you feel the Doctors should be aware of? *

Have you been diagnosed or received treatment for any of the following conditions: *

Is there any family history (either on your mother or fathers side) of male pattern baldness? *

Are you a smoker? *