Consultation NameEmailContact NumberScalp / Hair ConcernsCurrent Products UsedStress LevelsAverage Hours of SleepHow Is Your HealthGoodFairPoorHow Is Your DietGoodFairPoorAre You Currently On A Diet?YesNoHave you had any stress, shock or illness in the last 12 monthsDescribe your lifestyleAre you on any medication?How does your scalp look & feel?Have you any family history of scalp issuesHow many times a week do you wash your hair?After how many days after washing does your scalp and hair feel oily or dry?If you use conditioner how and what area of your hair do you apply it?Are you currently taking any vitamins?