Welcome! Thank you for taking the time to allow gilferrersalon.com evaluate your hair and scalp needs. You are now one step further in learning how your hair will make you look and feel sexier, more beautiful and desirable. Christopher Mackin our resident Trichologist will carefully analyze your information and in approximately ten days you will receive a diagnosis of your hair and scalp condition and needs. You will also receive a customized prescription of the Gil Ferrer Hair Products which will help you obtain healthy and sexy hair.

Please complete this page carefully. This questionnaire is confidential. It will be used only for the sole purpose of creating your personalizased hair diagnosis by our resident Trichologist, Christopher Mackin. It is important that all questions be answered carefully in order for us to arrive at your accurate hair type and condition. There is a charge of $10 for this service, which will be applied towards your next purchase of any Gil Ferrer Hair Care products.

Date:    Name:    Sex: M   F
Address:
City:    State:    Zip:
Home:    Work:     Email:
HAIR TYPE (describe the best you can) HAIR LENGTH (describe the length of your hair)
Coarse: straight  wavy  curly   frizzy
Medium: straight  wavy  curly   frizzy
Fine: straight  wavy  curly   frizzy
 
very short   short   chin length  
shoulder length   long hair   very long
HAIR CONDITION (describe the best you can) HAIR CUT (how often do you have your hair cut?)
healthy   dry   very dry
damaged   oily
 
every 4 weeks   every 8-12 weeks
every 6 months   once a year
     
SHAMPOO (how often do you wash your hair?) CONDITIONER (how often do you use a conditioner)
daily   every other day   weekly
every 2 weeks   once a month   never
Specify brand:   
shampoo 1:
shampoo 2:
shampoo 3:
 
daily   every other day   weekly
every 2 weeks   once a month   never
Specify brand:   
intensive 10-15 min heat conditioner
intensive 2-5 min conditioner
non-rinse instant conditioner
     
STYLING AIDS (specify brand) STYLING TOOLS YOU USE (specify brand)
styling lotion      styling cream
gel mousse    finishing product
hair spray    mousse
gel   wax   other
 
blow dryer   curling iron   
electric rollers    rollers
heating cap    other
     
COLOR PROCESS HAIR LOSS
Date of last chemical application:
permanent     semi-permanent
Is your hair chemically colored?  YES    NO
Is your hair highlighted?     YES    NO
Is your entire head highlighted? YES    NO
Is a toner used? YES    NO
 
Have you experienced excessive hair loss during the past:  
1-3 months     4-6 months     7-12 months
none     longer (please specify):
Does your hair have less volume than: 
1-6 months     7-12 months      1-3 years
If over 3 years please specify:
     
HAIR STRAIGHTENING (conventional) THERMAL RECONDITIONING (Japanese Straightening)
Date of last hair straightening procedure:
Type of product used:
Product brand used:
 
Date of last hair straightening procedure:
Type of product used:
Product brand used:
     
PERMANENT WAVE SCALP CONDITION
Date of last perm application:
Did the curl hold? YES    NO
Hair condition: healthy   dull
  dry   breaking
 
Scalp condition:   normal     dry     oily  
reddish areas      itching sensation
scaling      burning sensation
Frequency:  all the time periodic
Scalp products used:
     
YOUR AGE LIFE STYLE
12-18  19-24  25-34  35-39  40-44
45-49  50-54  55-59  60+
 
student professional
retired homemaker
     
HEALTH
Have you had a major illness in the past 5 years?   YES    NO
Have you had general anesthesia within the past 6 months?   YES    NO
Do you presently take any medications?   YES    NO   If YES, please specify
Have you given birth in the last 6 months?   YES    NO
Are you pregnant now?   YES    NO
Do you take any vitamins?   YES    NO   If YES, please specify
Do you have any allergies?   YES    NO   If YES, please specify
Please specify any special dietary programs you have followed in the past 2 years
 
Please charge $10 to my credit card for for analyzing my hair. I understand that the $10 will be deducted from my next purchase of Gil Ferrer Hair Products.
Name:    Credit Card:    Expiration: