Custom Hair Regimen Questionnaire


The purpose of the Custom Hair Care Regimen is to provide personalize recommendations for your individual hair problems, issues, and goals.

After you submit this form, we will address your specific concerns and provide you a custom regimen and recommended hair products. While we try to produce all consultations within 24 hours, it may take up to 48 hours to complete your Custom Hair Care Regimen.

What is the current state of your hair?*
Are you currently taking any prescribed medications?*
If yes, what medication(s)?
Are you currently taking any vitamins or hormones?*
If yes, what vitamins or hormones?
Do you have any known allergies? *
If so, what?
Have you ever been treated by a doctor for hair loss or a scalp problem?*
If yes, what was the diagnosis?
Have you ever had an adverse reaction to products, treatments, or chemicals used on your skin or scalp?*
If yes, please describe in detail.
What is your current hair length? (short, medium, shoulder-length, long)*
Do you presently have any breakage, thinning areas, shedding, or bald spots?*
If yes, where?
Do you suffer from a dry and/or itchy scalp?*
Have you ever had dandruff or flaking?*

 Hair Weave, Braids, & Extension History

Do you wear weave, braids, or hair extensions? (If no, please proceed to the next section.)*
If yes, please select the type(s) from the list below.
How long do you keep the weave or braids?

 Hair Maintenance & Styling

How would you describe the density of your hair?*
How often do you shampoo and condition your hair?*
What tools do you use at home to style your hair? Select all that apply.*
How often do you put heat on your hair?*
Please select any of the following hair services you’ve received within the past year.*
Please list any hair products you currently use on a regular basis.*
Which products do you like?
What are the preferred styles you wear?*
What are your long-term hair goals? (1-2 years or more)*
Is there any additional information you would like to share about yourself or your hair?

 Upload 4 Photos of Your Hair:

Right Side*
Left Side*