DigiCon

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(Kindly fill the relevant information or tick, as appropriate.)

Initials *

Age(in Years) *

Gender *

Male Female

H/O Alopecia *

Yes No

Family history of alopecia *

Yes No

Drug	Frequency of dosing
Topical minoxidil	OD BID
Oral finasteride	OD BID
Topical hair serums	OD BID
Topical minoxidil plus finasteride	OD BID

Co-prescribed with oral medication

Finasteride Dutasteride Biotin & Combination Iron supplements Any other

If any other, please specify

Scoring of side effects with Alcohol based Minoxidil & combination formulation: 4: Very severe, 3: Severe, 2: Moderate, 1: Mild: Absent