Hair & Scalp Health Assessment

Hair & Scalp Health Assessment

Restoring The Natural Beauty in You
Thank you for taking the time to complete this questionnaire. Your answers will help us create a personalized plan to address your specific hair and scalp needs. Let’s get started!
What is your primary hair concern?*

ThinningHair SheddingBald PatchesHair BreakageOther (please specify): ___________
How long have you been experiencing this issue?*

Less than 3 Months3-6 Months6-12 MonthsOver a Year
Have you been diagnosed with any scalp conditions?*

YesNoIf yes, please specify: ___________
Do you experience any of the following scalp issues?*

Dry or flaky scalpItchy scalpRedness or irritationOily scalpScalp tendernessOther (please specify): ___________
How would you describe your hair type?*

StraightWavyCurlyCoily
How would you describe your hair's condition?*

Dry and BrittleDamaged (heat/chemical)OilyNormalHealthy
Have you experienced significant hair loss due to any of the following?*

Pregnancy or childbirthHormonal changes (e.g., menopause)Stress or traumaWeight loss or dietingMedical conditions or medicationsOther (please specify): ___________
How often do you shampoo your hair?*

Daily2-3 Times a WeekOnce WeeklyBi-WeeklyLess than that
Have you used any hair loss or scalp treatments before?*

YesNoIf yes, what treatments have you tried and for how long? ___________
How would you describe your diet and nutrition?*

Balanced and healthySometimes healthy, sometimes notPoor dietCurrently taking supplements (please specify): ___________
How would you rate your stress levels?*

LowModerateHigh
Do you experience any of the following?*

Fatigue or low energyMood swings or irritabilityHormonal imbalancesDigestive issues
Are you open to natural or holistic treatments?*

YesNoNot Sure
What is your primary goal when it comes to your hair and scalp health?*

Stop hair lossRegrow hairTreat scalp conditionsStrengthen hairImprove overall hair and scalp healthOther (please specify): ___________
Have you had any recent changes to your health, medications, or lifestyle that might be affecting your hair?*

YesNoIf yes, please specify: ___________
Email*
example@example.com
Next Steps

Once you've submitted your answers, our expert team will review your responses and create a personalized hair and scalp health plan just for you. You’ll receive your plan via email, along with treatment options to help you achieve your hair goals!
Should be Empty: