HLCC Medical Questionnaire

Required Personal Information

Height:
Weight (in lbs): lbs 1kg = 2.2lb
Date of Birth:
Gender: Male Female

Please Answer the Following:
Check ONLY if you have any of the following medical problems

None (click here if you have none of the following)
Coronary Artery Diesase	Atherosclerosis
Low Blood Pressure	Liver Disease
Irregular heart beat / Cardiac Arrithymia	Kidney Disease
Congestive Heart Failure	Stroke
Valvular Heart Disease	Depression
Multiple Myeloma	Anxiety
Obesity	Schizophrenia
Hypertension	Spinal Cord Injury
Diabetes Mellitus / Diabetes	Endocrine Disorders
Prostate Cancer	Sickle Cell Anemia
Enlarged Prostate	Leukemia
Anemia	Low Testosterone
Thyroid Disease

If you have any of the above Medical Problems, Please Specify any current Medications.

Have you had a complete physical exam with blood tests with the last year?
yes no
Do you consume more than 2 servings a day of alcohol?
yes no
Do you smoke cigars or cigarettes?
yes no
If 'yes' how many per day?

Do you have any irregular heart beat or Cardiac Arrithymia?
yes no does not apply
Do you have low blood pressure?
yes no does not apply
Do you have any known allergies?
yes no
If yes, please list allergies:

Did you start losing your hair before the age of 30?
yes no
Are you currently taking any prescription medication?
yes no
If yes, please list medication and why:

Please answer the following questions if you are a female.

Are you planning to get pregnant in the next 6 months?
yes no does not apply
Are you currently pregnant or nursing?
yes no does not apply
Are you currently taking birth control pills?
yes no does not apply
Are you currently on hormone replacement therapy?
yes no does not apply
Have you had blood tests for thyroid abnormality or Anemia workup?
yes no does not apply
Do you have a Cystic Ovary Disease?
yes no does not apply
Are you a woman suffering from excess facial hair?
yes no does not apply

Please answer the following questions if you are a male ordering Propecia

Do you suffer from male pattern hair loss?
yes no
Have you currently had or plan to take a blood PSA blood test for the screening of prostate cancer?
yes no
Do you have Prostate Cancer?
yes no

Would you like to answer non safety questions which can help us better understand your condition and possibly help change or adjust your treatment program in the future?
yes no

Patient Responsibility Statement:
By submitting this consultation form I AFFIRM AS IF UNDER OATH AND STATE TRUTHFULLY that:
I have read my informed consent and patient responsibility statement:

* Click to read the Patient Responsibility Statement and Informed Consent