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Hair Assessment Survey

First Name

Last Name

Email

Phone

Gender

Female

Male

Condition

Shedding

Thinning

Bald patches

Receding hairline

Breakage

Shortened hair strands

Loss of volume

Location

Crown (top of head)

Edges/temple

Front Hairline

Patchy Ares

Left Side

Right Side

Back of Scalp

Diffuse (All Over)

Timeframe

<3 months

3–6 months

6–12 months

1–3 years

> 3 years

Symptoms

None

Itching

Burning

Tenderness

Flaking/dandruff

Redness

Inflammation

Pain

Hairstyles

Loose/natural

Braids

Weaves/extensions

Wigs

Tight ponytails/buns

Chemical relaxers

Heat styling

Styling

Daily

Weekly

Monthly

What medications do you use?

Birth control/HRT

Weight loss medication

Recent changes in your medication

Use

Oils

Serum

Medicated shampoos/conditioner

Supplements

Other

Hair loss

Sudden

Gradual

Cyclical

Family History

Hair thinning in family

Baldness (male or female relatives)

Unknown

Prior Treatment

Minoxidil

PRP

Steroid Injection

Prescription medications

Supplements

None

Sleep

<5hours

5-7 hours

7+hours

Diet

Balanced

Restrictive

High Protein

Vegan/Vegetarian

Goals

Regrow Hair

Stop Shedding

Improve thickness

Restore hairline

Improve scalp health

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The True
Root Health

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