Client Information

First Name *

Last Name *

Email Address *

Phone Number

Date of Birth

Age

Preferred Pronouns

City / State

How did you find us?

If referred, by whom?

Hair & Scalp Profile

What is your natural hair texture? Select all that apply

Straight (Type 1) Wavy (Type 2) Curly (Type 3) Coily / Kinky (Type 4) I'm not sure

How would you describe your hair density?

Thin / Fine Medium Thick / Coarse Mixed / Varies by area

How would you describe your scalp type?

Dry Oily Normal / Balanced Combination Sensitive / Reactive

Do you experience any of the following scalp conditions? Select all that apply

Itching / Irritation Flaking / Dandruff Tenderness / Soreness Tightness / Tension Excess Oil / Buildup Redness / Inflammation Psoriasis Seborrheic Dermatitis None currently

Where are you noticing the most thinning or hair loss? Select all that apply

Crown / Top of head Temples / Hairline Sides Nape / Back of head All over / Diffuse Edges / Perimeter Patchy areas Part line (widening)

What is the current length of your hair?

TWA / Very short Ear length Chin length Shoulder length Bra-strap length Waist length or longer

Hair Concerns & Shedding Pattern

What are your primary hair and scalp concerns? Select all that apply

Excessive shedding Thinning / Volume loss Slow / No growth Breakage / Brittleness Dryness / Lack of moisture Receding hairline Bald patches Scalp sensitivity Change in texture Premature graying

How long have you been experiencing hair loss or shedding?

Less than 3 months 3 – 6 months 6 – 12 months 1 – 3 years 3+ years Not sure

Approximately how many hairs do you lose per day (estimate across all shedding)?

Fewer than 50 50 – 100 (normal range) 100 – 200 More than 200 I haven't counted

When do you most notice shedding? Select all that apply

When washing When detangling / combing During styling On pillow / overnight Throughout the day (spontaneous) All of the above

Did anything happen around the time your hair loss began? Select all that apply

High stress / trauma event Hormonal change / perimenopause Pregnancy / Postpartum Surgery / Procedure New medication or change in meds Illness (COVID, infection, etc.) Significant diet change Nutritional deficiency diagnosis Rapid weight loss Nothing obvious / happened gradually

Please describe your hair concerns in your own words

Hair Practices & Chemical History

What chemical services have you received in the past 12 months? Select all that apply

Relaxer / Perm Permanent hair color Highlights / Bleaching Semi / Demi-permanent color Keratin / Smoothing treatment Texturizer Japanese / thermal straightening None — I'm fully natural

How often do you apply direct heat to your hair?

Daily Several times a week Weekly Monthly or less Never / Rarely

What protective styles do you currently wear? Select all that apply

Box braids Weave / Sew-in Wigs Faux locs Twists / Twist-outs Bantu knots No protective styles currently

How often do you wash your hair?

Daily Every 2–3 days Weekly Every 2 weeks Monthly or less

What hair products are you currently using?

Do you currently wear or have you recently worn tight styles (tight ponytails, braids, weaves)? These can contribute to traction alopecia

Yes, currently Yes, recently (last 6 months) No

Hormones & Medical Background

Where are you in your hormonal journey?

Pre-menopausal (regular cycles) Peri-menopausal (irregular cycles) Menopausal (< 12 months no period) Post-menopausal (12+ months no period) Surgical menopause I'm not sure

Have you been diagnosed with any of the following hormonal or medical conditions? Select all that apply

Hypothyroidism (underactive thyroid) Hyperthyroidism (overactive thyroid) PCOS Insulin resistance / Pre-diabetes Type 2 Diabetes Anemia / Iron deficiency Autoimmune condition (lupus, alopecia areata, etc.) Adrenal fatigue / Cortisol imbalance High androgens / DHT sensitivity Fibroids / Endometriosis None diagnosed Prefer not to say

Other conditions or diagnoses not listed above

Are you currently taking any medications or supplements? Include prescriptions, OTC medications, and supplements

Yes No

Please list your medications and supplements

Are you currently using or have you used HRT (Hormone Replacement Therapy)?

Yes, currently Yes, in the past No Considering it

Have you had relevant bloodwork done in the last 12 months? e.g. thyroid panel, ferritin, B12, vitamin D, hormones

Yes No Some tests, not all

Notable lab results or levels (optional)

Is there a family history of hair loss?

Yes – mother's side Yes – father's side Yes – both sides No Not sure

Nutrition & Digestive Health

How would you describe your current diet?

Omnivore (eat everything) Vegetarian Vegan Pescatarian Keto / Low-carb Gluten-free Other

How often do you eat protein-rich foods per day?

Every meal Once a day A few times a week Rarely

How much water do you drink daily?

Fewer than 4 cups 4 – 6 cups 6 – 8 cups 8 or more cups

Do you experience any digestive issues? Gut health directly impacts nutrient absorption and hair growth

Bloating Constipation Loose stools / Diarrhea IBS / Crohn's Acid reflux / GERD Food sensitivities None

Are you currently taking any hair, skin, or nail supplements? Select all that apply

Biotin Collagen Iron Vitamin D Zinc Omega-3 / Fish oil B Complex / B12 Magnesium Prenatal vitamins Multivitamin None currently

Additional notes about your diet or nutrition

Sleep & Stress

How many hours of sleep do you typically get per night?

Fewer than 5 hours 5 – 6 hours 6 – 7 hours 7 – 8 hours More than 8 hours

How would you describe your sleep quality?

Excellent (restful, uninterrupted) Good most nights Fair (some disruption) Poor (frequently disrupted) Struggling with insomnia

Do you experience night sweats or hot flashes that disrupt sleep?

Yes, frequently Yes, occasionally No

How would you rate your current overall stress level?

1 2 3 4 5 6 7 8 9 10

1 = Very low10 = Extremely high

What are your primary sources of stress? Select all that apply

Work / Career demands Financial pressures Family / Relationship stress Health concerns Caregiving (children / parents) Grief / Loss Low — I manage stress well

Do you have any regular stress-relief or self-care practices?

Exercise / Movement Meditation / Breathwork Journaling Therapy / Counseling Prayer / Spiritual practice Time in nature None at this time

Hair Goals & Expectations

What are your top hair goals? Select up to 3

Stop or reduce shedding Regrow lost hair Thicken existing hair Grow more length Achieve a healthy scalp Understand the root cause Build a sustainable routine Address hormones & hair together

What treatments or approaches have you tried before?

Minoxidil (Rogaine) Prescription hair medications PRP (Platelet-rich plasma) Scalp massage / microneedling Hair growth supplements Natural / Holistic approaches Hormone therapy for hair Nothing yet

If you've tried treatments before, what happened?

What does hair restoration success look like for you in 6 months?

How committed are you to making lifestyle changes as part of your restoration?

All in — ready for a full holistic approach Mostly — willing to make most changes Selective — small changes first Still figuring that out

Is there anything else you'd like us to know about your hair journey?

Consent & Scope of Practice

Please read the following carefully before signing.

Queen Bellis Crown Restoration provides holistic hair and scalp wellness coaching. Our services are educational and wellness-based in nature and do not constitute medical advice, diagnosis, or treatment. We are not licensed medical professionals, and our recommendations are not a substitute for the care of a qualified physician, dermatologist, or other licensed healthcare provider.

By completing and submitting this assessment, you acknowledge and agree that:

1. Scope of Services: The information, guidance, and recommendations provided by Queen Bellis Crown Restoration are for educational and wellness purposes only. You understand that results vary and are not guaranteed.

2. Medical Disclaimer: You are encouraged to consult with your physician or appropriate healthcare provider regarding any medical conditions, medications, or concerns before implementing any recommendations from our program.

3. Informed Participation: You voluntarily choose to participate in the Queen Bellis Crown Restoration program and take full responsibility for any decisions you make regarding your health and wellness based on our educational guidance.

4. Privacy: The information you provide in this assessment will be kept confidential and used solely for the purpose of personalizing your restoration program. Your data will not be sold or shared with third parties without your explicit consent, except as required by law.

5. Photography / Testimonials: With your separate permission (indicated below), we may use before-and-after photos or testimonials for educational or marketing purposes. This is entirely optional and will not affect the quality of services provided to you.

6. Age Confirmation: You confirm that you are 18 years of age or older.

I have read, understood, and agree to the Scope of Practice and Consent above. *

Yes, I consent to and agree with the above statements.

Photography / Testimonial Permission (optional)

Yes, photos and testimonials Testimonials only (no photos) No, I prefer to keep my journey private

Signature & Date

Full Legal Name (electronic signature) *

By typing your name above, you are providing your electronic signature and agree this carries the same legal weight as a handwritten signature.

Date *

All fields marked with ✦ are required. Your information is private and protected.

♛

Thank You, Queen.

Your assessment has been received. We will review your responses carefully and be in touch within 2–3 business days to schedule your personalized consultation.

Your restoration journey begins now.