Date
*
MM
DD
YYYY
Full Name
*
First Name
Last Name
Email
*
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Are you currently pregnant:
Yes
No
Menopausal:
Yes
No
Using contraceptives:
Yes
No
Hysterectomy:
Yes
No
Taking hormones:
Yes
No
Children:
Yes
No
Ages:
Occupation:
*
Is your hair currently relaxed or natural?
*
Yes
No
If natural, are you looking to keep your natural curl pattern?
Date of your last full relaxer or touch up:
MM
DD
YYYY
Applied by a professional or yourself/family member?
How often is your hair shampooed & conditioned?
*
By a professional or yourself/family member?
By a professional or yourself/family member?
*
Date of your last shampoo?
*
MM
DD
YYYY
Do you cold wash?
*
Yes
No
What was your hair color at birth?
*
Current hair color?
*
Have you ever received any of these color treatments?
*
By a professional or yourself/family member?
*
Date of your last color treatment?
MM
DD
YYYY
Do you sometimes suffer from a dry and/or itchy scalp?
*
Please Explain:
Is your scalp scaly? Please explain.
Has a medical professional given/prescribed the use of any shampoos, scalp creams, etc? Please explain:
Have you ever had a large amount of hair damaged or lost at one time? Please explain:
Do you feel like your hair sheds often?
*
Yes
No
Please explain:
Please list any recent significant life changes in the past 3 years (major medical diagnosis, weight gain/loss, car accidents, surgeries, births/deaths, job stress, unemployment, etc.)
Do you suffer from any allergies?
*
Yes
No
Please list/explain:
In the last 18 months, did you:
*
How did you hear about us?
*
Acknowledgement
*
Electronic Signature
First Name
Last Name
