Simple Online Doctor

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Patient Notice! This questionnaire forms the basis of your hair loss consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to safely prescribe medication and offer accurate advice. We expect you to read the medicinal information provided before using your treatment.

1Your Hair Loss

Please select the pattern of your hair loss according to the chart below.

Do you understand Propecia / Finasteride is for men between 18-65 only?

NOTE: Propecia / Finasteride will not work in women and can be harmful during pregnancy *

NoYes

You must understand this information to proceed. If you are not a male aged between 18 and 65, please refer to your GP for a face to face consultation.

ID and age verification are required prior to receiving treatment.

Was your hair loss either sudden or medication induced? *

NoYes

Please provide more information below. *

Does your hair fall out in patches? *

NoYes

Please provide more information below. *

Are you suffering from an illness or skin condition that might explain your hair loss? e.g. Disease causing weight-loss or fevers or skin conditions such as psoriasis or ring worm *

NoYes

Please provide more information below. *

Is your scalp red, inflamed, irritated, infected or painful? *

NoYes

Please provide more information below. *

Are you currently taking, or have you ever taken, Finasteride (Propecia) or Dutasteride (Avodart)? *

NoYes

Have you noticed you have developed, or did develop, any of the following since you started taking Finasteride (Propecia) or Dutasteride (Avodart)? *

Do you believe Finasteride (Propecia)/Dutasteride (Avodart) was the cause of this issue? *

NoYes

Do you believe Finasteride (Propecia)/Dutasteride (Avodart) was the cause of this issue? *

NoYes

Do you believe Finasteride (Propecia)/Dutasteride (Avodart) was the cause of this issue? *

NoYes

2Your health

Over the last 2 weeks, how often have you felt little to no interest or pleasure in doing things, especially those that you typically enjoy?

Over the last 2 weeks, how often have you felt down, depressed, or hopeless? *

Do you suffer from depression or take antidepressant medication? *

NoYes

How long have you been taking antidepressant medication and is it stable? Please provide details for our GPs to review *

Are you currently undergoing any investigations in relation to your prostate or have raised PSA (Prostate Specific Antigen) levels? *

NoYes

Please provide more information below. *

Do you have any other health problems or conditions that you think we should know about? e.g. recent or major operations, G6PD, mental illness, neurological conditions etc. *

NoYes

Please provide more information below. *

Have you previously been diagnosed with or currently have any of the following:

Prostate cancer
Severe liver impairment
Male breast tissue enlargement (Gynecomastia)
Kidney impairment
Breast cancer
Urine issues (such as difficulty urinating or obstructive uropathy)
Inflammatory bowel disease (such as colitis)

NoYes

Please provide more information below. *

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? *

NoYes

Please list your current prescription, over the counter and alternative medicine(s) including the dose. *

Are you using any medicines, creams or dressings for your scalp? *

NoYes

Please provide more information below. *

Do you have any known allergies to any medicine or substances? *

NoYes

Please provide more information below. *

3Consent

You should promptly report to your doctor any changes in your breast tissue such as lumps, pain, enlargement or nipple discharge as these may be signs of a serious condition, such as breast cancer.

Are you aware that some users of Propecia / Finasteride may experience depression or suicidal thoughts? Other people may experience decreased libido or sexual dysfunction.

NOTE: You should discontinue use and see your GP if you feel depressed or have any thoughts of self-harm when taking Finasteride. If you have previously suffered from severe depression or suicidal thoughts or attempts, you should not use this medication and contact your GP for advice. *

Confirm

I am aware that this medicine can pass into semen. I’m aware that I should use a condom when having sex if my partner is pregnant or could get pregnant. I understand that I should discontinue Finasteride (Propecia) treatment for 2 weeks, or Dutasteride (Avodart) for 3 months, before trying to conceive. *

Confirm

I'm aware that I should tell my GP I'm taking Finasteride if I have a blood test for prostate cancer called PSA (prostate-specific antigen). This is because finasteride can affect the result of this test. *

Confirm

I confirm I am over 18 years old.

The medicine ordered is for my sole use only.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Doctor terms and conditions. *

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

NoYes

Please enter the email address of your GP clinic *

As per Australian telehealth guidelines, all first time patients, those requesting a new treatment or those looking to renew a prescription must have a brief call with one of our doctors. Do you have reliable access to a video call device (phone/computer) or a phone to accept this call? *

NoYes

You require reliable access to the internet on a device which you can use to have a video consultation with the doctor in order to be suitable for telehealth. Please refer to your regular GP in person.

During your consultation the doctor may approve repeats of the medication for up to 12 months, subject to the specific treatment and your current health. Repeats during this period will be stored in your account and can be processed without the need for another consultation. Please confirm you understand this information. *

Confirm

If we are unable to assist via a telehealth consultation, you may be asked to seek alternative medical care such as that of a doctor in person. If this occurs you will receive a refund on your request.

Simple Online Doctor is a private clinic; the consultation and medication may be eligible for rebates through your private health cover, but are not covered by Medicare or the PBS. We conduct regular price reviews to ensure we are providing among the best value online.

Did you have difficulty understanding the English that is written in this assessment, affecting your ability to provide accurate answers or do you require language interpretation during a verbal consultation? *

NoYes

As you have difficulty understanding the assessment and or require interpretation services, you will be required to have an interpreter with you during your consultation with the doctor. You can access these services at Translating and Interpreting Services. Please confirm that you agree to organise an interpreter for your consultation.

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