Picture Perfect Consultation Form

“Making you look good makes me feel good”

(Please print legibly)

Note: All information contained in this form is kept confidential, and will only be used by Picture Perfect Hair by Maiysha Johnson solely for the purpose of determining hair care needs, suggested remedies and desired styling. Please bring form to consultation or email to [email protected].

Name: ______________________________________ Age: _______

Contact Phone: ___________________________________________

Email: __________________________________________________

How often do you shampoo your hair? _________________________

What type of shampoo do you use? ___________________________

What kind of conditioner do you use? __________________________

Is your hair thinning or breaking? ______________________________

List areas of hair loss or breakage. ______________________________

Any family history of thinning or balding? ________________________

What actions have you taken to prevent or correct hair loss or damaged hair?

______________________________________________________________________________

______________________________________________________________________________

What chemicals are you currently applying to your hair? ________________________________

How long is your hair? ___________________

How would you describe the density of your hair: fine, normal, or thick? __________________

Are you or do you? (check all that apply):

Dieting__ Allergies__ Medications__ Smoker__ Vitamins/Supplements__ Under Stress__

Hair Condition: (circle one) Straight Wavy Curly Excessively Curly

Oily os ow oc ec

Normal ns nw nc oec

Dry ds dw dc dec

How would you describe the condition of your scalp? (check one) oily__ dry__ Itchy__ flaky___

Do you or have you worn: braids, ponytails or cornrows? _______________________________

How would you describe your hairs condition? (check one) good ___ moderately good ___ fair ____ poor ___ seriously needs professional help ____