📞 (+44) 07770 474443 . ✉ enquiries@mmsclinic.co.uk

Free Discovery Call

Confidential • Clinically reviewed • Evidence based

This questionnaire helps our clinicians assess whether treatment for hair loss may be appropriate and safe for you.
Submitting this form does not guarantee treatment

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Step 1 of 10



Section 1 - About You

1. Are you completing this assessment for yourself? *
2. Sex at birth: *
3. Age (you must be 18–65 years): *

4. Contact details:

5. GP details (recommended for safe continuity of care):

GP Consent: *

Section 2 - Your Hair Loss

6. Are you currently experiencing hair thinning or hair loss? *
7. Which best describes your hair loss pattern? *
8. When did you first notice hair loss? *
9. How did the hair loss begin? *
10. Has your hair loss been: *
11. Does hair loss run in your family (parents or siblings)? *

Section 3 - Scalp & Skin Health

12. Do you currently have any scalp symptoms? *
13. Do you have patchy hair loss, scarring, or sudden complete hair loss? *
14. Have you been diagnosed with a scalp or skin condition (e.g., psoriasis, eczema, dermatitis, skin cancer on scalp, fungal infection)? *

If yes to questions 12–14, a clinician review may be required before treatment.

Section 4 - Medical History

15.1. Have you ever been diagnosed with any of the following? (Select all that apply)

Urological / Hormonal
Cardiovascular
Endocrine / Metabolic
Liver / Kidney
Other

15.2. PSA Monitoring / Prostate Cancer Risk

Are you undergoing PSA monitoring due to a personal or family history of prostate cancer? *

Section 5 - Mental & Sexual Health

Have you ever experienced: *
Do you currently have sexual health concerns, such as reduced libido or erectile difficulties? *

Section 6 - Medication & Allergies

18. Are you currently taking any medication or supplements? *
19. Have you ever used treatments for hair loss? *
20. Are you allergic or sensitive to any of the following? *

Section 7 - Lifestyle Factors

22. Smoking: *
23. Alcohol intake: *
24. Recreational drug use: *

Section 8 - Photos

Please upload clear photos of your scalp (front, top, sides and back). This helps clinicians accurately assess your hair loss pattern and scalp conditions that may contribute to hair loss/guide treatment options.

Photo Status: *

Please upload one photo for each view (Max 5MB each):

Section 9 - Understanding, Safety & Consent

Please read carefully and confirm each statement:

Section 10 - Consent

26. I consent to assessment via an online medical consultation pathway and understand that a clinician may request further information or recommend a face-to-face or video consultation if required for safety. *