New Client Info/Consultation Form

Please be assured that the information contained in this form will be kept strictly confidential and will be
used by Naturals Salon and Spa
Instructions for submitting: Use your word processor to fill out this form and save it as a file on your computer.
Then email the file as an attachment to naturalssalonandspa@gmail.com. You may also print out this form and
fill it out by hand. Then fax this form to: 804-859-5627
Name _______________________________________________________________ Age: __________
Contact Phone: __________________________ Email: ______________________________________
Occupation: __________________________________________________________________________
Employment Environment: Outside___ Inside___ Hot___ Humid___ Dry_____ Dirty____ clean____
Age(s) of children?: _______ Is your hair thinning or breaking? ___________
How often do you shampoo your hair? ___________ What type of shampoo do you use? ____________
How often do you condition your hair? ___________ What type of conditioner do you use? __________
When was your hair trimmed last? __________ List areas of hair loss or breakage. _________________
Any family history of thinning or balding? __________ How Long is your hair? ___________________
Have you sought professional help to correct hair loss or thinning? Dermatologist? Hair care specialist?
If so, what were the results of those visits? __________________________________________________
Do you bleach, press, relax or have your hair permanently waived? ________ When last? _____________
Other hair & scalp products used: i.e., hair spray, scalp cleansers, scalp oil, etc. _____________________
Are you now, or have you: (check all that apply)
Hair Condition: Straight Wavy Curly Excessively Curly (circle one)
Oily
Normal
Dry
Is your scalp: oily___ dry___ flaky/crusty ____ red/inflamed ____ itchy ____
Women only: pregnant? ____ menopausal? _____ menstrual cycle (regular/irregular) ____________
using contraceptives? _____ are you taking hormones? ______ hysterectomy? _____
Hair Maintenance:
Do you relax your hair? ____________ How often? ______________
What type of relaxer do you use (lye/no lye)? _______ When was your last relaxer? _______________
a.Worn a hair piece or wig b. Had hair transplants or fusion
c. Been on a diet d. Lost of gained more than 15 lbs in the past
e. Been eating a well balanced diet f. Been taking daily vitamins or supplements
g. Have any allergies h. Had a recent accident
i. Been using drugs or medications
j. Under excessive emotional distress
k. Been in good health
l. Subconsciously twist hair or scratch scalp
m. Been under a physician’s care
Who applied your last relaxer? ______________ Do you use color in your hair? __________________
Do you use permanent or semi-permanent color? __________ Do you use synthetic or human hair? ____
Do you or have you worn: Braids, weaves, dread locs, wigs, twists, corn rows or rubber bands?
Do you sleep in rollers? __________ Do you wrap your hair up at night? _________
How often do you use Hot curlers or other hot appliances on your hair? __________________________
In what condition is your hair? Good___ moderately good ___ fair ___ poor ___
seriously needs professional help ______
What do you do to your hair before going to bed? ____________________________________________
What do you do to your hair when you wake up? _____________________________________________
What is it that you would ultimately like to do or have done with your hair? ________________________
_____________________________________________________________________________________
Any other comments? ___________________________________________________________________