Follicle Fuel Hair Loss Intake Form Template
Follicle Fuel is a compounded hair restoration formulation addressing male pattern hair loss and scalp health. Because some components may affect sexual function, this intake form includes a sexual dysfunction baseline screening section. Providers use this form to document hair loss symptoms, screen for sexual health side effects at baseline, and identify contraindications including cancer, liver disease, and drug interactions.
Free Template
Follicle Fuel Hair Loss Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Follicle Fuel Hair Loss 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.
5 Sexual Function Baseline
Some hair loss medications may affect sexual function. Please document your current baseline.
Sexual Function Baseline
Some hair loss medications may affect sexual function. Please document your current baseline.
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.
Follicle Fuel is a compounded formulation. Dispensing pharmacy must be licensed. See FDA: https://www.fda.gov/drugs/human-drug-compounding
5-alpha reductase inhibitor components require sexual dysfunction baseline documentation. Post-finasteride syndrome has been reported. Patients should be counseled on potential sexual side effects before initiating therapy.
St. John's Wort is a CYP3A4 inducer and should not be taken concurrently with medications metabolized by this pathway.
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Sources & References
Frequently Asked Questions
Why is sexual function screened before hair loss treatment?
Some hair loss medications (particularly those containing finasteride or dutasteride) can cause sexual side effects including decreased libido, erectile dysfunction, and ejaculation disorders. Baseline sexual function documentation protects both the patient and provider.
What is post-finasteride syndrome?
Post-finasteride syndrome refers to persistent sexual, neurological, and psychological side effects reported by some patients after discontinuing finasteride. While its existence is debated in the literature, patients should be informed and baseline function documented before starting therapy.