Medical Questionnaire

Required Personal Information

Name:

  

E-Mail:

  

Height:

   4 5 6 ft 0 1 2 3 4 5 6 7 8 9 10 11 inches

Weight: (in lbs)

  1 2 3 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 lbs 1kg=2.2lb

Date of Birth:

0 1 2 3 4 5 6 7 8 9 10 11 12 / 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985

Gender:

Male   Female

Please Answer the Following:

Check if you have any of the following medical problems

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

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

Have you had a complete physical exam with blood tests within the last year?

   Yes   No

Do you consume more than 2 servings a day of alcohol?

   Yes   No

Do you smoke cigars or cigarettes?
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?

If yes, please list allergies: 

    Yes   No

  

Did you start losing your hair before the age of 30?

   Yes   No

Are you currently taking any prescription medication?

If yes, please list medication and why: 

   Yes   No

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

Do you suffer 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

By checking the following box and submitting this consultation form I AFFIRM AS IF UNDER OATH AND STATE TRUTHFULLY that I have read my informed consent and patient responsibility statement.