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Full Address |
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Postcode |
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Telephone |
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email |
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1) |
How often do you wash your
hair? |
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2) |
What type of Shampoo do you
use? |
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3) |
Do you use a conditioner,
moisturiser, reconstructrant or similar product? |
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No
Yes
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4) |
Has your hair been
chemically processed, e.g. coloured, permed etc? |
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No
Yes
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5) |
What length is your hair? |
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6) |
Do you use any of the
following products? |
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Hair
Spray
Mousse
Gel
Wax
Other Products
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7) |
Do you use heat to dry or
style? |
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No
Yes
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8) |
Please describe any
problems with your hair:-
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9) |
Please describe any
problems with your scalp:-
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10) |
If you have any skin
allergies to cosmetics please specify:-
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11) |
Have you contacted your
doctor, Dermatologist or Trichologist in the past
relating to your concerns? If so please give details.
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12) |
Do you wear your hair in
braids, cane/corn row, wefts, hair extensions? |
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No
Yes
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13) |
How often do you have your
hair cut? |
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14) |
Have you ever had your hair
permed, coloured, straightened or relaxed?
Please
specify and give details of when and how often.
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15) |
Please very briefly state
anything else of relevance
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Please supply 4 hair
samples from right side, left side, crown and back of
the head for microscopic examination. |
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When you have completed
all of the questions above, please print out this form
and attach your samples. Please send it together
with a cheque for £10 made payable to MAISON
WHITEHEAD to;
The Birmingham
Trichology Centre, 57 The Ridgeway, Chasetown,
Burntwood, Staffs, WS7 4SP |
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