We are going to ask you a few questions so that we can give you the best medical care. It will take an average of 5 minutes to complete this form. We always try our best to help our patients, but due to some circumstances it means our online service sometimes is not able to meet all your needs. Please be honest in your responses and if you are unsure about any of the questions, check these with your GP first.
I am 18 years old or above
I am using this service for my own self, of my own free will and any treatment or advice is for my sole use only
I will contact my GP if I need help filling out this form, reading or understanding this consultation
I understand my consultation will not be passed to the Volumize Hair Ltd clinicians until I have completed the questionnaire in full.
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What gender were you assigned to at birth?
Male Female
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How old are you?
Under 18 18-20 20s 30s 40s 50s 60+
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What are your aims from this treatment?
Regrow my hair Prevent further hair loss Regrow and prevention
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What changes do you anticipate Volumize will bring to your life??
Increase my hair Feel less anxious Improve my mood Better success in relationships Reduce stress I'm not sure
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Which one of the below images best describes your hair loss?
Bald 1 Bald 2 Bald 3 Bald 4 Bald 5 Full Bald
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Have you experienced rapid hair loss or hair loss in specific patterns (e.g., male pattern baldness)?
Yes If yes more details box No
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Are you currently experiencing any scalp or skin conditions that may affect the use of hair loss medications (e.g., scalp infections, psoriasis, eczema)?
Yes If yes more details box No
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Have you previously tried any hair loss treatments or remedies?
Yes if yes more details box No
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Do any of the following apply to you?
I have a previous diagnosis of breast cancer or prostate cancer, or I am presently undergoing PSA (prostate monitoring). I have uncontrolled high or low blood pressure. I am currently dealing with, or have a history of, depression, anxiety, or panic disorders. None of the above
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Do you suffer from any of the following conditions?
Significant or Chronic Kidney Disease. Phaeochromocytoma.
Heart attack, stroke, or mini-stroke within the last 6 months.
Chest pain symptoms or any heart rhythm issues. Heart valve
problems. Disease of the heart muscles. Get breathless or have
chest pain with light exertion, such as walking briskly for 20
minutes or climbing two flights of stairs
Yes No
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Do you have any history of allergies (eg Minoxidil, Finasteride, Dutasteride)?
Yes No
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Is your scalp prone to dryness, irritation, or dandruff?
Yes- I would like a scalp sensitive plan No- I want the recommended plan
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Are you currently being treated for any other medical condition?
Yes if yes more details box No
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What’s important to you?
Maximizing my results Minimizing side-effect risks Better hair texture Novel treatments (as typical treatments, e.g. Regaine, hasn’t worked for you)
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Do you understand and agree with the following?
I will read the enclosed patient information leaflet before I begin using my medicines
I will be the exclusive user of any medication provided to me via this service.
I have completed the medical questionnaire accurately and to the best of my knowledge
I will inform my regular GP about my treatment
The treatment is an unlicensed preparation manufactured in the UK.
It may take up to 6 months before I begin to see the effects of my treatment
Pregnant women should not be exposed to Finasteride or Dutasteride. I will not use the treatment if my partner is pregnant or trying to become pregnant
I will seek medical attention and stop taking the treatment if I experience any adverse side effects
If I have a blood test measuring my PSA levels, Finasteride and Dutasteride may alter the result and I will inform my doctor that I am taking this medication
My scalp is healthy and free of cuts, burns and inflammation
During my treatment, I understand that it is my duty to notify Volumize Hair Ltd of any new diagnoses of medical conditions made by a clinician, including any new medications that I will start taking.
I Understand
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