Hair Questionnaire

Hair Questionnaire

What does your hair need?
Hair Questionnaire

Let's develop your perfect hair regimen!
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Step 1: Current Hair Regimen + Hair Goals
How long have you been natural?
Hair LossDamaged Hair (from heat or relaxers)Curl DefinitionVolumeDandruff or itchy scalpHair BreakageDetanglingSplit endsFrizzy HairOther
Please provide some more detail on your top 4 hair challenges?

What is your CURRENT hair care routine? Please describe it from wash day to daily maintenance. Be very specific! What methods and products do you use?

Rows	Product(s)	Routine
Cleanse
Conditioner
Leave-in/Moisturizer
Styler
Night-time routine
Daily/Weekly Maintenance
Other

How would you describe the current condition of your hair? (e.g. dry, damaged etc.)
What are your hair goals? Be as specific as possible and set SMART goals.
My hair goals
Step 2: Nutrition + Wellness Assessment
NUTRITION INTAKE

The types of food you eat and how frequently you eat can affect the health and growth of your hair.

Please provide a typical day's diet.

Rows	Meal time	Description
Breakfast
Snack
Lunch
Snack
Dinner
Other

YesNoType option 4
YesNo
If yes, which one?
YesNo
If yes, how much?
List any other supplements you are taking:
Are you following any specific diet or nutrition plan? If yes, please describe.
HEALTH + MEDICAL HISTORY
HypothyroidismHyperthyroidismAnemiaLupusArthritisHigh blood pressureDiabetesHormonal imbalanceUlcersParkinson’s DiseaseEpilepsyGout
High cholesterol medicationsChemotherapy medicationsAntidepressantsThyroid medicationsOral contraceptive medicationsBlood thinnersAnticonvulsantsColchicine
STRESS

Any interference that disturbs a person's healthy mental and physical well-being can cause stress. There is evidence that acute and/or chronic stress may trigger certain hair loss conditions.
Please rate your current level of stress (over the past 3 months) on a scale of 1-8. Please circle the number(s) that apply.

1

2

3

4

5

6

7

8

1 is Not stressed, 8 is Extremely Stressed
Step 3: Hair Type & Texture Assessment

Please take a look at the images below. Which curl patterns MOST CLOSELY resembles yours?
HAIR TYPE

Wavy Hair: Type 2 Characteristics
- Wavy hair has “S” shaped curls down its length or much of the hair can appear straight with slight bends
- Can frizz easily
- Doesn’t have a lot of bounce and body
Curly Hair: Type 3 Characteristics
- Curls down the entire length of the hair shaft
- Curls are well-defined and often springy
- Strand thickness can be from fine to coarse
- Frizz, lack of curl definition, shrinkage and dryness are challenges
- Curly Hair: Type 4 Characteristics
  Tightly curled or kinky hair has the tightest curls
- Hair fiber diameter can range from fine and thin to wiry and coarse
- A lot of densely-packed strands
Which curl patterns MOST closely resembles yours?
HAIR TEXTURE

Knowing the texture of your hair is another tool to classify your hair type. It assesses your hair’s overall shine, sheen, feel and response to wetting.
What would you say is your hair texture?

STRAND THICKNESS

This refers to the thickness of each individual strand of hair and can range from fine to thick (coarse). You can assess the width of your hair by taking a piece of your hair from a brush or comb and comparing it to a piece of thread.  

Take a piece of your hair and then compare it to a strand of thread to determine the width/thickness of your hair. Then look at the descriptions below to find out the characteristics of your hair.

SRAND THICKNESS	DESCRIPTION
FINE	The most fragile and can be easily damaged Can be oilier than other hair types Difficulty holding a style Structurally fine hair has two layers: a cortex and cuticle It can become weighed down with product and look thin Breaks easily
MEDIUM	The most common hair type; covers the scalp well Not as fragile as fine hair and can be manipulated into styles easily Structurally it usually has two layers: the cortex and cuticle and may contain the medulla It’s not as prone to breakage as fine hair
THICK	This hair texture is strong Structurally it contains all three hair layers: the medulla, cortex and cuticle Holds styles well This hair texture usually takes longer to dry than others Resistant to chemical treatments Tolerates heat well Resists breakage better than fine or medium hair

What would you say is your strand thickness?
DENSITY

Refers to how closely individuals hair strands are packed together on the scalp and it ranges from low density to high.

How to Assess:
- Start with dry hair and let the hair hang loose
- Look at the hair closely from different angles
- If the scalp is visible - low density
- If some of the scalp is visible - medium density
- If it’s difficult to see the scalp - high density
What would you say is your hair density?
Step 4: Hair Health Assessment
LowMediumHigh
It stretches quite a bit before it breaksThe hair snaps as soon as there is any tension put on it
I commonly find knots in my hairI see strands with mid shaft splitsI have hair loss and thinning around the hairlineMy hairline becomes thin whenever I wear weaves, braids and cornrowsI live in an area where there is hardwaterMy hair is prone to tangling and knotting
On wash days I have less than 10 broken strands and on non-wash days I have fewer than 5 broken strandsThere is very little hair in the comb or brush after detanglingAfter styling hair covers my skin and the floorI have patches on my head where there is no hairAfter detangling and combing I lose large clumps of hairI have thinning short pieces of hairVery large clumps of hair are lost during tangling and styingMy hair is dry and brittle
My hair is soft with a lot of elasticityI frequently use chemical processes like bleaching, permanent colours and texturizersI comb and brush my hair when dryMy hair frequently feels dry and I have to apply moisturizer every dayI don’t take a lot of time to detangle my hair
Heat Damage

Please answer the following questions with respect to heat damage.
How many times a week do you use heat on your hair?
What type of heating appliance(s) do you use?
What is the temperature reading or the temperature setting?
Do you have pieces of hair that won't go back to their original curl pattern?
Thank you for filling out the form! The information you have shared will be discussed during our one on one hair consultation and help us come up with a personalized hair regimen just for you!

Once you have made a payment for the consultation, you will be contacted via email to book the consultation.
Consultation Price: $75 for a $45 minute session

If you are in Canada, you can e-transfer to this email: naturallyevelyn@gmail.com.

If you are outside Canada, please select from the following payment methods:
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Hair Questionnaire

Hair Questionnaire

Step 1: Current Hair Regimen + Hair Goals

Step 2: Nutrition + Wellness Assessment

Step 3: Hair Type & Texture Assessment

Step 4: Hair Health Assessment