Hair Restoration Program Form

Hair & Scalp Assessment Form

Welcome to Root Revival! 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? *
Please note, I will be reaching out by email to confirm your appointment
Phone Number*
Please note, I will respond by text to confirm your appointment
May I leave personal messages on this phone number?*

YesNo
What is your mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Occupation*
Please list all known allergies*
Do you have a shellfish allergy?*

YesNoNot Sure
Have you had any recent surgeries or been given anethesia?*

YesNo
How would you describe your daily stress level?*

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?*
Please check all that apply to you:*

StrokeIrregular heartbeat/ Congestive heart failureDepressionEndocrine disorderHigh blood pressureAnemiaThyroid conditions/PCOSDiabetesSkin Conditions/ EczemaMenopauseAnxiety/ High stressLiver diseaseRapid weight gain/lossRecent loss of a loved oneLupusNone of the aboveOther
Have you been diagnosed with any kind of cancer or received chemo treatments?*

YesNo
Are you experiencing hair loss on any other parts of your body besides the top of your head?*

YesNo
Please list all prescribed medications and vitamins you are currently taking?*
Please write down what a standard day of eating looks like for you? Breakfast, lunch, dinner, snacks, drinks? Please be as specific to everything you are eating and drinking so that I can properly put together a nutritional guide for optimum hair health.*
Please list what foods or drinks you tend to crave. What types of foods are your favorites? *
Do you struggle with any digestive issues? Be as specific as possible. (constipation, diarrhea, stomach pain or discomfort, bloating, gas, IBS issues?) *
Would you be open to eating gluten free?*

YesNoAlready are
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? What type of exercising do you do?*
Have you recently had any diet changes?*

YesNo
Are you perimenopausal or menopausal? Experiencing any irregularity in periods?*

YesNo
Are you pregnant or trying to conceive? Or have you recently just gave birth?*

PregnantTrying to conceiveJust had a babyNot at this time
Are you currently taking birth control pills or hormone medication?*

YesNo
Family History: Check anyone in your family that has experienced hair loss*

FatherMotherGrandparentAunt/UncleSiblingNo known family history
When did you start to notice your hair loss?*
Have you had Covid?*

YesNo
Did you notice any hair loss during or after?*
If you received the Covid vaccine, did you experience any complications after?*
What hair and scalp products do you use currently? Please list the brands and type so we can be sure you are using products that support the health of your hair. *
Do you apply conditioning masks to your hair? Conditioning masks are different than everyday conditioner. These are masks/treatments that contain more intense amount of hydration to the 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?*
Do you currently or have you worn hair extensions?*

YesNo
What have you tried to help with your hair loss so far?*

TransplantsOver the counter productsPrescription productsHair loss clinicMinoxidilHaven't tried anything yet
Do you eat animal protein?*

YesNo
How is your sugar intake?*

HighMediumLow
Do you eat a lot of processed foods?*

HighMediumLow
Do you smoke cigarettes?*

YesNo
Is your scalp:*

Dry or flakingOilyNormal
Have you experienced dandruff or itchy scalp recently?*

YesNo
Have you experienced any attacks of patchy large areas of hair loss?*

YesNoNot sure
Please take pictures of the areas of concern so I can get a closer look. Save these pictures so you have your starting point pictures and can track your progression as you move through the program.

Top of head
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Hair line
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File Upload

Left Side Hairline
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File Upload

Right Side Hairline
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File Upload

Back Crown Area
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The programs and help I offer requires commitment. The results will very based on the level of commitment. Are you willing to stay committed and wait at least 6 months to see results with the program I create for you?*

YesNo
Is there anything else you would like me to know about your hair, lifestyle habits, scalp or things that will help me know more about you in creating your most perfect hair healing personalized plan?*
I am being evaluated at Root Revival and understand that I will first undergo a comprehensive preliminary evaluation by a hair loss practitioner, Michelle DeLuco. I further understand that although XTC products and laser light therapy has had many successful results, each client is different and like any cosmetic treatment, results will vary depending on my commitment to the changes needed to be made and the use of products. I acknowledge that it is my responsibility to inform Michelle DeLuco of any changes in my health condition no matter how minor.
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Hair & Scalp Assessment Form