SELF ASSESSMENT QUIZ

Take our Self Assessment Quiz from the privacy of your own home.

Taking the time to reflect and answer some of all of the following questions can help to determine the next step.

What are your immediate goals for your hair?

Click the button below the image that is most similar to your hair:

Have you visited a doctor or dermatologist for a diagnosis?

Yes No

If so, when and what was the diagnosis?

When did you start noticing your hair thinning?

Can you think of anything that could have triggered the thinning? (ex: medication, genetics, diet, or stress)

Are you currently using or have you tried any topical solutions and/or medication for hair loss?

What were your results?

Have you tried scalp treatments? Laser hair therapy? Hair replacement?

Do you personally know a Hairline Creation client?

Yes, I do No, I do not

If so, who?

Are you preoccupied by thoughts/worries about your hair?

Yes, I am No, I am not Sometimes

Are you avoiding social situations because of your hair?

Yes, all the time! No, never. At certain times

What kind of work do you do? (Outside and physical or inside and sedentary?)

Did either parent or grandparent have hair loss? If so, at what age?

Do you prefer a gradual processes or an extreme makeover?

Gradual Processes... Extreme Makeover!

How often do you get your hair cut?

Every week Every two weeks Every month Every two months Every three months Longer

What products do you use on your hair?

Do you play any sports and/or workout regularly?

Yes No

Are you limited to one style to cover up your thin area(s)?

Yes No

Do you notice more hair than before coming out when you wash your hair and/or brush it?

Yes No

Have you ever known anyone personally who had hair extensions, transplants, wigs, and or hair systems?

Yes No

What was their experience? Did they like it?

Did their hair look natural?

Yes No

What circumstances make you uncomfortable with your hair? (ex: I avoid swimming because when wet my hair looks thinner)

How long have you been searching for a solution to your problem?

Several days A few weeks Months Years

When you have your full head of hair back, what are 2 things you are excited to do that you have not been able to enjoy recently?

Please include any comments you wish to make on this subject in the space provide below.

Name:
E-mail Address: (we do NOT share your info!!)
Home Phone #:
Alternate Phone #:
Home Address:
City:
State:	- Please Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
I would prefer Hairline Creations to contact me via:	e-mail Home Phone Alt. Phone U.S. Mail any method

After you complete this Self Assessment please use the "Submit" button above to send the information to a member of our team of professional consultants and stylists. ALL information is held in the strictest confidence. We will contact you with our analysis and to arrange a FREE consultation during which we will discuss with you the options available.

We will have you looking and feeling better in no time. Thatís our promise!