Finasteride Intake Form Template
Finasteride is a 5-alpha reductase inhibitor FDA-approved for male pattern hair loss (androgenetic alopecia) and benign prostatic hyperplasia. It works by reducing dihydrotestosterone (DHT) levels, the primary androgen responsible for follicle miniaturization. This intake form documents hair loss symptoms, baseline depression status, and screens for contraindications including liver disease, prostate cancer, and St. John's Wort use.
Free Template
Finasteride Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Finasteride Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Contraindications
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Finasteride is FDA-approved for male pattern hair loss at 1 mg/day (Propecia) and BPH at 5 mg/day (Proscar). Off-label doses or compounded formulations require additional informed consent. See FDA: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020788s020lbl.pdf
Finasteride is teratogenic to male fetuses. Women of childbearing potential must not handle crushed or broken finasteride tablets.
Depression screening at baseline is important as psychiatric side effects including depression and suicidal ideation have been reported. See FDA labeling for current warnings.
St. John's Wort is a CYP3A4 inducer and can reduce finasteride plasma levels, reducing therapeutic efficacy.
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Sources & References
Frequently Asked Questions
How long does it take for Finasteride to show results for hair loss?
Finasteride typically takes 3-6 months to slow hair loss and 12 months or more before significant regrowth is visible. Patients who discontinue therapy will see hair loss return within 6-12 months.
Does Finasteride affect PSA levels?
Yes. Finasteride typically reduces PSA levels by approximately 50%. Providers must account for this when interpreting PSA results for prostate cancer screening. A PSA level on finasteride should be doubled for comparison to normal reference ranges.