Free Hair Consultation With Gashee Subscription

Active Subscribers Only. All Submissions Will Be Validated. 

    1. Gender

    2. Choose the color below that most closely describes your natural hair color?

    3. From the list below choose the texture that best describes your natural hair. Choose all that apply.
    4. Please mark how often you groom your hair in each of the following styles.
    (1 = Never, 2 = Seldom, 3 = Occasional, 4 = Often, 5 = Most of the time, 6 = Always)










    5. Regarding Straightening, how often have you done the following?
    (1 = Never, 2 = Occasionally, 3 = Off and on over the years, 4 = Moderate Use; stopped more than 3 months ago, 5 = Heavy use; stopped more than 3 months ago, 6 = Currently using)


    6. Please state how often you wash your hair.
    (1 = 7 times a week, 2 = 3-4 times a week, 3 = 1-2 times a week, 4 = Every 2 weeks, 5 = Every 3 weeks, 6 = Every 4 or more weeks)



    7. Please state how often you Condition your hair.
    (1 = 7 times a week, 2 = 3-4 times a week, 3 = 1-2 times a week, 4 = Every 2 weeks, 5 = Every 3 weeks, 6 = Every 4 or more weeks)




    8. Please indicate your use of the following nonprescription hair treatments.
    (1 = Never used, 2 = Used more than a year ago, 3 = Used 6 months ago, 4 = Used 3 months ago, 5 = Currently using)


    9. If you have tried other hair treatments what has been your experience? (Specify Product Name)











    10. Referring to the pictures on the hair loss chart provided at the end of this questionnaire, please indicate the extent of hair loss.
    Female:

    Male:
    11. If you have ever been treated by a doctor for hair loss what was the diagnosis?

    12. Mark any of the following tests you've had for hair loss. Mark all that apply.

    14. If you've ever been treated by a doctor for hair loss, please provide the type of treatment, duration of treatment.

    15. Mark any of the following conditions that you have. Choose all that apply.

    16. Please list any prescription medications you are currently taking or have taken in the past.
    17. Please list any over-the-counter medications you are currently taking or used in the past.
    18. Please list any herb, vitamins, or natural supplements you are taking or used in the past.
    19. Please indicate if you are allergic to any of the following. Check all that apply.
    Any plant or plant extractAny flower or flower extractAny oilsOther: (Please Specify)

    20. Please use the space below to explain anything else you think would be helpful for us to know about your hair condition hair grooming habits or medical condition that we did not thing to ask.

     
     
     

    Send head shots that show the balding areas. Please pull back any hair that obscures the true state of your hair line. If possible also send some photos with the entire top of the head wetted.

    Include the photos of the side and back of your head. If you are having body hair transplanted, please include photos of the hair bearing areas of your body from which you want the hair taken.

    If you are unsure, send photos of all hair bearing areas. Include photos of special recipient areas such as scars, eyebrows, eyelashes, mustaches, etc.

    5MB Max file size limit, PHOTOGRAPHS UPLOAD:

     
     

     

    Female Hair Loss Pattern

    hair1

    Male Hair Loss Pattern

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