Posted on January 9, 2026April 28, 2026 by Akbari Team Hair and Scalp Questionnaire Hair and Scalp Questionnaire – Lisa Akbari Trichologist Lisa Akbari Hair and Scalp Questionnaire Please fill out this form with as many details as possible about your hair and scalp needs. Contact Information Name * Email * Phone Number (Cell) * Secondary Phone Number Hair Information Hair Texture Naturally Straight Naturally Kinky Chemically Treated Hair Color Type Permanent Color Temporary Color Rinse No Color Treatment Does your hair feel dry? Yes No Does your hair look dry? Yes No Scalp Information Does your scalp itch? Yes No Does your scalp feel tender and sore? Yes No Does your scalp burn? Yes No Does your scalp have bumps? Yes No Does your scalp have bald spots or short broken areas? Yes No Location of bald spots (if applicable) How long have you had balding? (if applicable) Hair Care Routine How long is your hair? (inches) How often do you shampoo your hair? How often do you condition your hair? Do you use leave-in conditioner? Yes No If yes, how often do you use leave-in conditioner? Describe your hair regimen Other issues, challenges, or tell us your hair story Hair and Scalp Care Goals What are your primary hair and scalp goals? (Select all that apply) Promote hair growth Increase hair thickness Improve moisture/hydration Improve scalp health Reduce breakage Treat dandruff Increase shine and luster Improve hair texture Length retention Other Please describe your specific hair and scalp care goals in detail What is your desired timeline for achieving these goals? Select a timeline 1-3 months 3-6 months 6-12 months 1 year or more No specific timeline Submit Questionnaire
