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Hair Assessment Form

A lot of the people contacting me are from the US or from out of town. If you're one of them, this section is for you! As so many of you have asked me to do, in the past I was unable to help you because in order for me to ascertain whether I can perform Japanese Thermal Reconditioning/TR on your hair or not, I have to first analyze your hair. Now with this form I can do that without you having to make a trip all the way to Toronto. This hair analysis procedure will reveal the condition of your hair.

This form will help me determine the structural competency of the hair and help interpret my findings before you make the trip for TR. This way I can get important information about your general health and habits and hair treatments and care.

To visually examine and testing the mechanical strength of the hair fiber and make any necessary preliminary evaluation, I will also need to evaluate hair samples. The hair samples taken must be representative of the entire head of hair.

All you have to do is fill out the form below. Then click on the "Display Form Input" button at the bottom of the form. You will see a new browser window with all your inputs. Make sure all the fields are correct. Then print the form and follow the instructions on the form to attach hair samples (hair diagram will print with the form even though you won't see it in the window). Then mail it to the address available on the form.

Do you have a problem area where: a) Color fades more rapidly. b) Areas that do not hold a set or style. c) Areas that are unmanageable or reveal breakage. For any of the above conditions, take extra hair samples from any problem areas.

Client Information

Name:
Gender:
Address:
City:
State or Province:
Zip or Postal Code:
Country:
Home Phone:
Work Phone:
Date of Birth:
Email:
How long does it take for your scalp to get oily after you shampoo?
Do you Experience and of these skin conditions? (Check all that apply)Dandruff  Flaking
Itching  Breakage
Scalp Condition:
Do you have any allergies?
Nails:
General Health:

Texture and Condition

Ethnic Origin:
Hair Distribution:
Hair Shape (Check all that apply)Straight  Wavy
Curly  Overly CurlyFrizzy
Hair Texture:
Do your Hair Styles Last?
Hair Condition:
Manageability:
Hair Length:
Body:
Sheen and Luster:

Prior Treatments

Have you used Henna on your hair?
If yes, what was the date of your last Henna application?
Have you had your hair chemically straightened before?
If yes, what was the date of your last chemical straightening?

Hair Maintenance

How often do you shampoo?
What brand of shampoo do you use?
Do you use a tar based shampoo?
Do you use a sulphur based anti-dandruff shampoo?
Do you use a conditioner?
What brand of conditioner do you use?
Do you use a Hair Dryer?
If so, how often?
Do you use a Flat Iron?
If so, how often?
Please type any additional information that you might consider relevant. (This info, no matter how minute, will help evaluate your particular hair condition)
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