Name

Last Name

Email

Type 1 - Straight (No relaxer, European)* Type 1 - Straight (No relaxer, European)* A - Fine, thin, shine B - Medium texture; easy to curl C - Resistant to curly; more coarse

Type 2 - Wavy* Type 2 - Wavy* A - Fine, thin, easy to style B - Naturally wavy, close to head C - Frizzy, coarse

Type 3 - Curly "S" Shaped** Type 3 - Curly "S" Shaped** A - Shiny and loose B - Bouncy ringlets; loose spiral curls C - Tight curls and coils

Type 4 - Kinky* Type 4 - Kinky* A - Tight "S" curls B - No curl pattern C - Tight curls and coils

Shaft/Follicle Assessment Shaft/Follicle Assessment Dry Dull Oily Frizzy Normal Combination Split Ends Breakage Color/Bleached

Scalp Assessment Scalp Assessment Dry Flakey Oily Damaged Burns/Scarring Bumps at Shaft Thinning Hair Loss/Alopecia Breakage Sensitive scalp

Medical Conditions Medical Conditions Lupus Cancer Dermatitis Psoriasis Eczema Cancer Auto-Immune Deficiency Syndrome Covid-19

Medications (Please list any medications that you are taking at this time)

Medical Concerns. Please list any known allergies below.

Carrier Oils (Choose up to 3) Carrier Oils (Choose up to 3) Sweet Almond oil - Soothes and moisturizes the scalp, helps breakage Coconut oil - Softens hair and increases shine; helps control frizzes Jojoba oil - Moisturizes the hair, adds nutrients, and stimulates scalp Olive oil - Retains moisture in the hair; removes dandruff, helps hair growth Avocado oil - Retains moisture Castor oil - Increases blood flow to the scalp None of the above

Essential Oils (Choose up to 3) Essential Oils (Choose up to 3) Cedarwood oil -Stimulates the scalp and promotes hair growth Clary Sage oil - Promotes hair growth and stimulates the scalp Lavender oil - Deep conditions the hair keeps it shiny, and helps control dandruff Rosemary oil -Stimulates the roots, improves hair growth, and increases circulation in the scalp Sandalwood oil -Helps with dry ends, and adds fragrance to the hair Peppermint oil - Increases scalp circulation Tea Tree oil - Improves scalp health Lemongrass oil - Helps moisturize and has a fresh scent None of the above