RxAdam
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ED & HAIR LOSS
ENHANCEMENTS
Generic Viagra – Sildenafil
Cialis
Generic Cialis Tadalafil
Hormone Replacement Therapy
URGENT CARE NOW
HAIR LOSS
Finasteride
Hair Power Pack
About RxAdam
Hair Loss Online
GET A FREE HAIR LOSS DR VISIT
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Step
1
of 10
How long ago did you first notice any signs of hair loss?
Just this month or sooner
1-6 months ago
Over 6 months
No hair loss yet, hoping to prevent it
Other
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Where are you noticing hair loss?
*
Hairline
Top of head
Patchiness
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Next
Are you currently experiencing any of the following? Different patterns of symptoms can suggest different possible causes.
Dandruff
Losing hair all over my body
Pain or burning of your scalp
Red rings on scalp
Very itchy scalp
Other
None
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What other symptoms have you noticed? Tell us more.
*
What treatments have you already tried? We want to know what has and hasn't worked in the past.
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Minoxidil or Rogaine
Biotin
Nioxin
Finasteride or Propecia
Saw Palmetto
Shampoo or Oil
Other
None
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Next
Do other people in your family have hair loss?
*
No
Yes
What relatives have hair loss?
*
Mother's side
Father's side
Other
What is your gender? We ask this question of all of our patients to ensure that we provide you with safe and effective care. We are inclusive of all people.
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Man
Woman
Transgender man
Transgender woman
Genderqueer/non-binary
Agender
Questioning
Another gender
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What was your sex assigned at birth? For example, on your original birth certificate
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Male
Female
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Do any of the following currently apply to you? Certain conditions can complicate diagnosis, increase risks, or change the recommended treatments so it critical we know everything going on with your health.
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Mild dandruff
Scalp psoriasis
Severe dandruff
Scalp eczema
No, don't have any of these
Do you experience any symptoms of sexual dysfunction?
*
Yes
No
Which of the following do you experience?
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Trouble getting or maintaining an erection
Low sex drive
Premature ejaculation
Other
What treatments have you sought for trouble getting or maintaining an erection?
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Viagra (Sildenafil)
Cialis (Tadalafil)
Levitra (Vardenafil)
Topical anesthetic spray, gel, or wipes
Condom use
Start-stop method
Prozac (Fluoxetine)
Paxil (Paroxetine)
Zoloft (Sertraline)
Anafranil (Clomipramine)
Other (injections, implants, vacuum pumps, herbs, supplements)
None of these
Please tell us more about your other symptoms of sexual dysfunction.
*
Do you have or have you had any medical or mental health conditions? Even if they are in the past certain conditions can complicate diagnosis, increase risks, or change the recommended treatments so it critical we know your full history.
*
No
Yes
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Which of the following medical conditions have you had or currently have?
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Diabetes
High blood pressure
Asthma
Breast cancer
HIV
Liver problems
Lupus or discoid lupus
Problems peeing
Problems with your immune system (other than HIV)
Prostate cancer
Prostate enlargement
Recurrent fungal infections
Rheumatologic conditions or autoimmune disease
Thyroid problems
Depression
Anxiety
Bipolar disorder
Schizophrenia
Borderline personality disorder
History of suicidal thoughts or plans to hurt yourself
I have another medical condition
In the last two weeks, have you been troubled by any of the following?
*
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling nervous, anxious, or on edge (enough that it impairs your ability to function at work or at home)
Worrying too much about different things (enough that it impairs your ability to function at work or at home)
No, I have not felt down, anxious, nervous, etc. in the last 2 weeks.
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How often have you felt this way (feeling extremely nervous, anxious, or on edge) in the last 2 weeks?
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How often have you felt this way (feeling extremely nervous, anxious, or on edge) in the last 2 weeks?
*
How often have you felt this way (little interest or pleasure in doing things) in the last 2 weeks?
*
1-2 days per week (several days)
3-4 days per week (more than half the days)
Nearly every day
Have you ever had any surgeries or hospitalizations? Include any significant emergency room visits, hospital stays, or surgeries, including cosmetic surgeries.
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No, never had surgery or been hospitalized
Yes
What surgeries or hospitalizations have you had? List all the procedures and events and try to estimate when they occurred.
*
Do you currently take any medicines, herbals, or supplements? Please include any medicines you finished recently, including topical medicines, and any injections, vitamins, herbal remedies, or any other products you use.
*
No, not taking any medicines, supplements, herbals, or other prescriptions
Yes
Please list the names of the medications, herbals, and/or supplements that you use. Please list the name, dose, and why you are taking each medicine or supplement.
*
Do you have any allergies or medication reactions? Please include any allergies or major reactions to medicines.
*
No, don't have any allergies or medication reactions
Yes
Previous
Next
You are now ready to submit to your Doctor.
Please enter you Date of Birth... Month- Date-Year.
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