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What is your date of birth?

BLOOD PRESSURE IN LAST 6 MONTHS

Please enter a recent blood pressure taken within 6 months. If you have not had your blood pressure taken with the last 6 months or do not know your blood pressure, please call your doctor. Another great way to get a recent blood pressure reading is to stop by your local pharmacy. Most local pharmacies including, Walgreens, provide FREE blood pressure checks for people 18 years and older. It is important we have a recent blood pressure in order to asses medical safety. You should not take this medication if you have high blood pressure. Blood pressure should be checked yearly.

HEART ATTACK IN LAST 6 MONTHS

HISTORY OF SEVERE CARDIAC DISEASE

HAS YOUR FATHER HAD A HEART ATTACK BEFORE THE AGE OF 55?

HAS YOUR MOTHER HAD A HEART ATTACK BEFORE THE AGE OF 65?

HISTORY OF SEVERE LIVER DISEASE OR LIVER FAILURE?

HISTORY OF SEVERE KIDNEY DISEASE OR KIDNEY FAILURE?

HISTORY OF PEPTIC ULCER DISEASE?

HISTORY OF BLEEDING DISORDERS?

CONGENITAL QT PROLONGATION

This is an abnormal heart rhythm you were born with

SPINAL CORD INJURY OR PARALYSIS?

PREVIOUS PROBLEMS WITH ED MEDICATIONS?

WHAT PROBLEMS?

HISTORY OF PEYRONIE'S DISEASE?

DO YOU HAVE ANY OF THE FOLLOWING? CHECK ALL THAT APPLY?

WHEN DID YOUR ED BEGIN?

HAVE YOU TRIED OTHER METHODS FOR ED?

ARE YOU CURRENTLY BEING TREATED FOR OTHER MEDICAL CONDITIONS?

WHAT MEDICATIONS ARE YOU TAKING? PLEASE INCLUDE OVER THE COUNTER MEDICATION AND HERBAL SUPPLEMENTS AND VITAMINS *DO NOT USE ED MEDICATIONS IF YOU ARE ALSO TAKING NITRATES

IS THERE ANYTHING ELSE WE SHOULD KNOW?

DO YOU HAVE ANY ALLERGIES?

TREATMENT OPTIONS

CHOOSE THE PICTURE THAT BEST REPRESENTS YOUR DEGREE OF HAIR LOSS.

WHEN DID YOU FIRST NOTICE HAIR LOSS?

HAVE YOU TRIED HAIR LOSS TREATMENTS BEFORE?

HAVE YOU BEEN DIAGNOSED WITH OR HAVE THE FOLLOWING CONDITIONS? PLEASE CHECK ALL THAT APPLY

DO YOU HAVE INCOMPLETE HAIR LOSS IN OTHER PARTS OF THE BODY?

Where?

HAVE YOU RECENTLY STARTED A NEW MEDICAL TREATMENT, SUCH AS CHEMOTHERAPY?

HAVE YOU BEEN DIAGNOSED WITH OR HAVE THE FOLLOWING CONDITIONS? PLEASE CHECK ALL THAT APPLY

ARE YOU CURRENTLY TAKING ANY MEDICATIONS PLEASE INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL AND VITAMIN SUPPLEMENTS

ARE YOU ALLERGIC TO MEDICATIONS?

IS THERE ANYTHING ELSE WE SHOULD KNOW?

TREATMENT

PROPECIA GENERIC FINASTERIDE. FINASTERIDE IS AN ORAL MEDICATION THAT BLOCK DHT FORMATION. THE MEDICATION IS A 1MG TABLET TAKEN ONCE DAILY WITH OUR WITHOUT FOOD. IN 6-12 MONTHS MEN SAW ON AVERAGE 10 PERCENT MORE HAIR. AFTER 2 YEARS ON AVERAGE MEN SAW 25% MORE HAIR. FINASTERIDE NOT ONLY HELPS TO REGROW HAIR BUT PREVENTS FURTHER LOSS. COMMON SIDE EFFECTS (~10%) ARE DECREASE IN LIBIDO, ERECTILE DYSFUNCTION, EJACULATORY DYSFUNCTION. SYMPTOMS RESOLVE AFTER STOPPING THE MEDICATION. STOP THE MEDICATION AND SEEK MEDICAL TREATMENT IF YOU EXPERIENCE ENLARGED BREAST TISSUE, TESTICULAR PAIN, OR DPERESSION.

PLEASE ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

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