Restoration Course Assessment

Hair Health Assessment: Discovering Your Key Factors

Welcome to Root Revival's Hair Assessment Questionnaire! I'm so excited to help you begin restoring your hair health. Please take a moment to fill out the following questions so that I have all the information needed for our coaching calls and to personalize your hair restoration program that is just right for you. These questions will help me learn more about your daily activities, your nutritional intake, what you are struggling with most and so much more. If you have any questions or need support, please email me at rootrevivalrestore@gmail.com. Be as thorough and as honest as you can be in answering (there is never any judging in my heart) so that I can best support you and set you up for your ultimate success! I look forward to helping you restore your hair growth and create your most beautiful hair crown! Lots of love, Michelle
What is your full name?*

First NameLast Name
What is your email address you used when you signed up for the course? *
Phone Number*
Format: (000) 000-0000.
What is your mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about me?*
Age
FemaleMale
Occupation*
Please list all known allergies*
YesNoNot Sure
YesNo
LowMediumHigh
Please let me know a little of your daily stress? Work, personal, health concerns, family, etc? *
Do you pull your hair or struggle with trichotillomania?*
StrokeIrregular heartbeat/ Congestive heart failureDepressionEndocrine disorderHigh blood pressureAnemiaThyroid conditionsDiabetesSkin Conditions/ EczemaMenopauseAnxiety/ High stressLiver diseaseRapid weight gain/lossRecent loss of a loved oneLupusNone of the abovePCOSOther
YesNo
YesNo
Please list all prescribed medications and vitamins you are currently taking?*
Please describe a standard day of eating? Breakfast, lunch, dinner, snacks, drinks?*
Have you experienced or had any bloodwork show deficiencies? (Iron, vitamin D, vitamin B, etc.)
Do you drink coffee or soda? How much do you drink each day?*
How much water do you drink each day?*
Do you exercise regularly? If so how often do you exercise per week? *
YesNo
YesNo
PregnantTrying to conceiveJust had a babyNot at this time
YesNo
FatherMotherGrandparentAunt/UncleSiblingNo known family history
When did you start to notice your hair loss?*
Is your hair loss sudden or has it been occurring gradually over time?
How many times per week do you shampoo?*
Do you apply conditioning masks to your hair? How often?*
Do you use heat tools to style? If yes, do you apply a thermal protectant before you use them?*
Do you pull your hair back in tight ponytails? How often?*
YesNo
TransplantsOver the counter productsPrescription productsPRP TreatmentsMinoxidilNutrafolHaven't tried anything yet
YesNo
HighMediumLow
HighMediumLow
YesNo
Dry or flakingOilyNormal
YesNo
YesNoNot sure
Is there anything else you would like me to know about?*
Disclaimer:

I am not a medical doctor, and the information provided in this hair assessment is for informational purposes only. It is intended to give you a better understanding of your overall health and wellness. Any recommendations or insights provided should be discussed with your healthcare provider before making any changes to your diet, lifestyle or treatments. This assessment aims to help Michelle, your Hair Loss Practitioner, gather relevant information to develop the most effective and personalized plan for your hair restoration. Always consult with a qualified healthcare professional for medical advice and medication changes.
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Hair Health Assessment: Discovering Your Key Factors