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What We Treat
Hair Loss
Sexual Health
About Us
Free Consultation
EN
AR
Menu
Home
What We Treat
Hair Loss
Sexual Health
About Us
Free Consultation
EN
AR
Home
What We Treat
Hair Loss
Sexual Health
About Us
Menu
Home
What We Treat
Hair Loss
Sexual Health
About Us
Free Consultation
EN
AR
Appointments
Wal
Sa
December 23, 2022 10:00 am
Date of Birth:
27/07/2024
Phone Number:
+20 100 234 0567
Email:
ws@modus.vc
Medical information
Edit
Hair loss location:
Crown
Hair loss progress:
3- 6 months
Scalp problems:
Yes
Previous treatments:
Hair transplant
Family history:
No
Pre-existing conditions presence:
No
Pre-existing conditions:
On medications:
No
Existing medications:
Has allergies:
Yes
Allergies:
Doctor Feedback
Add note
Start
I have confirmed the ID of this patient
Yes
No
Consultation Method
Telephone
Asynchronous Message
I have introduced myself, explained the scope of service and made patient aware of their rights – consent obtained to proceed
Yes
No
History
Presenting Complaint
Hair loss
History of Presenting Complaint
Past Medical History (to be cross check with pre-screening questionnaire)
Yes
No
In case the answer is “Yes”, use the text below to input to add any extra information
Drug History
Yes
No
In case the answer is “Yes”, use the text below to input to add any extra information
Allergies
NKDA (No Known Drug Allergies)
Use the text below to input to add any extra information
Family History
Yes
Use the text below to input to add any extra information
Social History
Alcohol Consumption/Body Mass Index/Smoking/Stress
Psycho-Social Impact
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Ideas, Concerns and Expectations
Examination
Please comment on the attached photo of the patient’s hairline
No photo provided
Use the text below to input to add any extra information
Diagnosis & Management
Diagnosis
Male Androgenetic Alopecia
I suspect an alternative diagnosis and I have excluded this patient from the Habib Hair Loss Pathway, please state findings
Use the text below to input to add any extra information
Management Plan
Prescription Issued
Minoxidil advice only
I have undertaken a risk/benefit discussion
Topical Minoxidil/Finasteride Issued
I have undertaken a risk/benefit discussion
No prescription issued
Use the text below to input to add any extra information
Safety Netting & Follow Up Plan
Time Taken for Consultation (minutes)
Submit consultation
