SORTEDMEN Quiz Page

1. About the customer

Collect identity, eligibility and treatment preference for prescribing safety.

1.1 What is your date of birth?

Must be between 18 and 65 years of age.

1.2 Were you assigned male at birth?

Yes No

1.3 Is this treatment for your own use?

Yes No

1.4 Which treatment would you like us to assess?

2. Pattern and history of hair loss

Determine whether the presentation is consistent with male-pattern hair loss.

2.1 Did your hair loss begin gradually?

Yes No

2.2 Did the shedding or hair loss begin suddenly?

Yes No

2.3 When did you first notice the change?

Less than 3 months 3-12 months 1-5 years More than 5 years

2.4 Is thinning affecting your hairline, temples, top or crown?

Hairline Left Temple Right Temple Top / Crown

2.5 Do you have one or more separate bald patches?

Yes No

2.6 Have you lost all or nearly all of the hair on your scalp?

Yes No

2.7 Have you also lost hair from your beard, eyebrows or body?

Yes No

2.8 Does a biological relative have a similar pattern of hair loss?

Yes No I don't know

2.9 Could change be linked to recent illness, stress or rapid weight loss?

Yes No

2.10 Could a medicine, supplement or condition contributed?

Yes No Unsure

2.11 Please upload current scalp photographs (Required for Clinical Verification):

1. Hairline

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2. Left/Right Temples

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3. Top / Mid-Scalp

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4. Crown

Choose Image Preview

3. Scalp health assessment

Topical treatment should only be considered for a normal, healthy scalp.

3.1 Is the skin on your scalp currently healthy and unbroken?

Yes No

3.2 Is your scalp red, inflamed, painful or persistently itchy?

Yes No

3.3 Do you have sores, psoriasis, eczema or sunburn on your scalp?

Yes No

3.4 Are you using a dressing or medical covering on your scalp?

Yes No

3.5 Are you using a medicated shampoo, steroid or lotion on scalp?

Yes No

3.6 Is your scalp currently shaved?

Yes No

4. Previous hair-loss treatment

Collect treatment history, response and adverse effects.

4.1 Have you used any hair-loss treatment before?

Yes No

5. Mental and sexual health

Crucial baseline evaluation for oral finasteride prescribing safety.

5.1 Ever diagnosed with depression, anxiety or mental health condition?

Yes No

5.2 Have you ever experienced suicidal thoughts or self-harm?

Yes No

5.3 Are you CURRENTLY experiencing severe low mood or suicidal thoughts?

Yes No

5.4 Before treatment, have you experienced reduced sex drive?

Yes No

5.5 Before treatment, experienced difficulty with erections?

Yes No

5.6 Before treatment, experienced ejaculation or fertility problems?

Yes No

6. General medical history

Conditions relevant to finasteride or minoxidil safety.

6.1 Noticed breast lump, enlargement, pain or nipple discharge?

Yes No

6.2 Had prostate enlargement, prostatitis, cancer or urinary difficulty?

Yes No

6.3 Are you due to have, or monitored with, a PSA blood test?

Yes No Unsure

6.4 Do you have liver disease?

Yes No

6.5 Diagnosed with high or low blood pressure?

Yes No

6.6 Have heart disease, angina, heart attack or abnormal rhythm?

Yes No

6.7 Experience unexplained chest pain, fainting or swelling?

Yes No

6.8 Do you have kidney disease?

Yes No

6.9 Any other medical condition not mentioned?

Yes No

7. Medicines and allergies

Capture prescription, non-prescription and non-medical drug use.

7.1 Currently taking any prescription medicine?

Yes No

7.2 Use pharmacy medicine, supplements, or performance drugs?

Yes No

7.3 Currently taking finasteride, dutasteride or DHT blocker?

Yes No

7.4 Taking medicine for blood pressure or heart?

Yes No

7.5 Allergic reaction to finasteride, minoxidil or excipients?

Yes No

8. Finasteride safety confirmation

Please actively review and confirm each safety warning statement.

8.1 Finasteride can cause sexual side effects (reduced sex drive, erection/ejaculation issues). Symptoms may continue after stopping.

I Understand Discuss First

8.2 Finasteride has been associated with low mood, depression and suicidal thoughts. If experienced, stop treatment & contact clinician.

I Understand Discuss First

8.3 Seek medical advice if noticing breast lump, enlargement, pain or nipple discharge.

I Understand Discuss First

8.4 Must inform clinician performing a PSA blood test that you take finasteride.

I Understand Discuss First

8.5 Pregnant persons must not handle crushed or broken finasteride tablets.

I Understand Discuss First

8.6 Male fertility effects reported. Discuss with prescriber if trying to conceive.

I Understand Discuss First

9. Topical minoxidil safety confirmation

Safety notices for topical minoxidil solutions or combination treatment.

9.1 Minoxidil must only be applied to a healthy, dry scalp as directed.

I Understand Discuss First

9.2 Using more than recommended amount will not improve results and increases side effects.

I Understand Discuss First

9.3 Temporary increased shedding can occur during first few weeks of treatment.

I Understand Discuss First

9.4 Stop using and seek advice if developing chest pain, rapid heartbeat, faintness or swelling.

I Understand Discuss First

9.5 Must keep away from children, must not be swallowed or transferred to skin.

I Understand Discuss First

10. Customer declaration

All statements must be actively accepted before submission.

Information provided is complete and accurate to best of knowledge. I am requesting treatment for my own use. I will read patient information leaflet and safety card. I will use treatment only as instructed. I will report side effects & health/medication changes. I understand completing consultation does not guarantee prescription. I understand prescriber makes final decision. I consent to information review by clinician & dispensing pharmacy. I have capacity to make healthcare decisions.

Full Name Signature:

Date of Consultation:

11. Contact and delivery information

Please provide your contact details so our medical prescribers can process your assessment and get in touch with you.

11.1 First Name

11.2 Last Name

11.3 Email Address

11.4 Phone Number

11.5 Delivery Address

11.6 Postcode / ZIP Code

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