The 5 Things Your Hair & Scalp Need!
Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your major hair concern? Select all that apply.
*
Breakage
Dryness
Brittle
Shine
Not soft enough
Manageability
Strength
Rough
Knots
Dullness
Tangles
Uneven curls
Hairstyles
Other
On a scale of 1-10, 10 being the best what would you rate your hair condition?
*
1
2
3
4
5
6
7
8
9
10
What is the major concern for your scalp? Select all that apply.
*
Itchy
Dry
Tightness
Flaky
Eczema
Dermatisis
Psoriasis
Alopecia
None
Other
On a scale of 1-10, 10 being the best what would you rate your scalp?
*
1
2
3
4
5
6
7
8
9
10
What food and non-food allergies do you have or had? Select all that apply.
*
Nuts
Penicillin
Sulfate
Sulfur
Fish
None
Shell Fish
Corn
Wheat
Dairy
Gluten
Latex
Eggs
Aloe
Other
What health conditions exists? Select all that apply.
*
Heart disease
High Blood Pressure
Pregnant
High Cholesterol
Anemia
Lupus
None
Diabetic
Vitamin D
Gut Health
Iron
Menopause
Perimenopause
Vitamin B12
Vitamin B6
Vitamin B2
Vitamin K2
Other
What best describes your hair routine?
*
Please Select
Go to the salon weekly.
Go to the salon bi-weekly.
Go to the salon once a month.
Do my hair at home weekly.
Do my hair at home bi-weekly.
Do my hair at home once a month.
Do my hair in between salon visits.
I have a non license professional do my hair.
I have a professional and non professional do my hair.
I...
*
Please Select
have small kids (teens), and I struggle with their hair.
am a stay-at-home parent.
like doing my hair, but I don't know how to style it.
don't like doing my hair.
want to get better at doing my hair.
work and have small kids (teens).
work from home.
work from home with small kids (teens), etc.
have mixed kids (teens).
have mixed hair.
don't want to do my kid's (teen's) hair.
Complete the sentence.
What would you like more clarity about your hair and scalp?
*
For instance, hairstyling for your hair and lifestyle, oiling your scalp, hair oil or hair moisture which is good for me?
0/25
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
*
Submit
Should be Empty: