hair scalp assessment

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Please take your time to complete this assessment. It may take a while to complete and you may have to think about your answers. Your input is vital to our hair and skin professionals developing an effective hair and scalp regimen for you.

After you complete this assessment form, submit it, and our Hair Care Professional will respond via e mail or telephone to your request.

All information collected is considered highly confidential. The conclusion of our assessment is not intended to replace the advice of a licensed health practitioner or Doctor.

Hair and Scalp Assessment (all information collected is treated confidentially)

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name

E-mail Address*
E-mail Address*

City*
City*

State/Prov*
State/Prov*

Country*
Country*

Home Phone

Fax

Age

Occupation

Employment Environment

	Outside
	Inside
	Hot
	Humid
	Dry
	Dirty
	Clean

Do you have children?

	Yes
	No

What is your scalp issue?

	Balding
	Irritated
	Flaky/crusty
	Oily
	Dry
	Boils
	Red/inflamed
	Bumps
	Boils
	Hair loss
	Itchy

In what areas of your scalp do you experience your scalp issue?

	Crown
	Hairline
	Temple
	Mid back
	Sides
	Lower back
	Nape
	Other

What areas of your scalp is your hair loss (balding and thinning from the roots)?

	Crown
	Hairline
	Temple
	Mid back
	Sides
	Lower back
	Nape
	Other

What areas do you experience breakage or thinning?

	Crown
	hairline
	Temple
	Mid back
	Sides
	Lower back
	Nape
	Other

How often do you shampoo your hair?

What type of shampoo do you use?

How often do you condition your hair?

What type of conditioner do you use?

Do you have a family history of hair loss or scalp issues?

	Yes
	No

Do you use chemicals on your scalp?

	No chemicals
	Relaxer
	Bleach
	Hair Color
	Medication

Other hair and scalp products used:

Tell us more: do you, are you, have you been?

	In good health
	Take vitamins or supplements
	Been on a diet
	Have allergies
	Wear a hairpiece
	Use drugs or medications
	Had surgery requiring anesthesia
	Had hair transplant
	Lost or gained 10 lbs
	Worn any adhesive on your scalp
	Had a recent accident
	Under emotional stress
	Lost someone close to you within 2 yrs
	Have cancer or had treatment for cancer
	Been under a physicians care

Have you sought professional help for your hair loss or scalp issue?

	Dermatologist
	Internal Medicine Doctor
	Natural Path Doctor
	Kineosiologist
	Hair Care Specialist
	Other

If so, were you tested and diagnosed with a particular condition through:

	Biopsy
	Scalp samples
	Hair samples
	Saliva test
	Blood test
	Scalp evaluation

What were the conclusions of your visits?

For women only, are you:

	Pregnant
	Menopausal
	Use contraceptives
	Take hormones
	Had a hysterectomy

Hair Maintenance: Do you relax your hair? How often? Last relaxer?

Do you use hair color? When was your last color applied?

	Permanent
	Semi permenent
	Demi permenent
	Rinse
	Natural hair dye

How often do you use hot curlers, blow dryers, or heated utensils on your hair?

Do you wear:

	Hair extension
	Braids
	Sew in weave
	Bonded weave
	Wig
	Lace front wig
	Infusion
	Locs
	Twists
	Cornrows
	Rubber bands
	Sleep in rollers or bonnet
	Wrap hair at night

Is the condition of your hair:

	Good
	Fair
	Poor

What is your ultimate goal with your hair and scalp?

Please enter the word that you see below.