Quiz – Hair Loss

Men’s Health – Hair Loss
Pre-consultation Assessment

Please complete this short quiz to book in your initial consultation. It will only take 5 minutes and will help our doctors better understand your unique circumstances.

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Name
Current Address
You will receive a confirmation to this email address.
Date of Birth
What was your sex at birth?
Are you pregnant or breastfeeding?
Do you have a Medicare number or IHI?
Just to be cautious, do you suffer from any of the following?
Do you take any medications, supplements or hormone therapy?
Are you trying for a baby or is your partner currently pregnant?
Have you had any major surgery?
Do you use any recreational drugs?
How often do you exercise?
Do you drink alcohol?
Do you smoke or vape?
How many coffees or other caffeinated beverages do you drink per day?
How would you rate your average night's sleep?
How would you rate your mood recently?
A few questions about your specific condition – only a health practitioner will see this information.
Is there a family history of hair loss?
When did you first notice your hair loss?
What results are you looking for?
How much body hair do you have?
14. Have you ever seen a doctor or specialist for hair loss?
Have you treated hair loss before?
Do you confirm that the information you have given is true and accurate, and is solely for yourself and if prescribed a medication, you will review the information supplied regarding the medication and side effects?