Frizzy Hair Diagnosis Questionnaire

FRIZZY OR SEMI-FRIZZY HAIR
Centre Clauderer Questionnaire - TO PRINT OUT

Centre Clauderer 346, rue Saint-Honoré 75001 Paris - Tel : +33 (0)1 42 61 28 01

To receive an In-Depth Clauderer Diagnosis, please print the questionnaire* and return it to the above address. Please include a sample of some hairs, along with 20€ (special web offer). You may pay by credit card. You are unable to print the form? Just send us an email to info@clauderer.com. We will instantly post it out to you.

• Mr • Mrs • Miss

• Surname (in capitals)

• First name

• Address (in capitals)

• Telephone (optional)

• E-mail (optional)

*The following questionnaire may seem long, but you will not regret the effort. The diagnosis you will be receiving is not a one-size-fits-all document. It is a full check-up of your hair’s health, which you will find nowhere else. According to a test carried out this current year, 92% of the respondents said they had been surprised by the quality and relevance of our expertise.

TO SEND US A SAMPLE OF A FEW HAIRS:

1 - Right before shampooing, run your hand through your hair, from the roots to the ends. Repeat the movement several times, so as to collect some hairs from three different places: the top of the head, the sides and the nape. Place the collected hairs in the frames below, and fixate them with adhesive tape.

2 - Also collect all of the hairs that will have fallen during the shampoo. Collect them all, without taping them, and insert them in an envelope, which you will include in your mailing.

Some hairs from the top of the head*...

from the sides*...

from the nape*...

*The hair samples from those zones will enable us to carry out a laboratory analysis of the cause of their eventual thinning out.

YOUR HAIR IS :

Natural

Permed

Coloured

With locks

Straightened*

* If you straighten your hair, how often (per year)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

* When was your last straightening session? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AND YOUR HEAD OF HAIR IS*:

*Do not worry if you do not know how to precisely answer some of the questions asked below: the hair analysis will make up for eventual approximations.

On the whole of the head	Thick	Mild	Weak	Scattered
On the top of the head	Thick	Mild	Weak	Scattered
Towards the back	Thick	Mild	Weak	Scattered
On the sides	Thick	Mild	Weak	Scattered
On the frontal zone	Thick	Mild	Weak	Scattered
On the nape	Thick	Mild	Weak	Scattered

YOUR HAIRDRESSING:

Do you use one or several greasy substances for your hair?

yes

If so, vhat type ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How often? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Have you already had small braids? Add-ons?	yes	no
Regularly?	yes	no

If yes, approximately for how long?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you currently have small braids?	yes	no
Are you currently wearing add-ons?	yes	no
Do you notice that such hairdressing causes a frontal recession of your hair?	yes	no

Do you (often), (sometimes), or (never) wear a wig? (circle what best describes your case)

YOUR SHAMPOOS :

Every 2 weeks or less	Twice a week
Once a week	Three times a week or more

After how many days does your hair start to grease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YOUR SCALP

Do you have dandruff?	yes	no
Does it remain on the scalp?	yes	no
How many days after shampooing does it appear?
Do you use an anti-dandruff shampoo?	yes	no
Do you suffer from itchiness?	yes	no
How many days after shampooing does it appear?
Does your scalp sweat when you make a physical effort?	yes	no

HAIR LOSS

Does your hair currently fall more than it should?

yes

If yes, for approximately how long has this been the case? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If yes, how would you qualify the hair loss you notice: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intensity	weak	mild	strong
Frequency	continuous	in fits and starts	at the beginning of seasons

If yes, which of the following reasons do you think can favour the loss?

personal problems	child-delivery (for women)
problems at work	illness (specify)
psychological shock	medical treatment
heredity	hairdressing (straightening, add-ons)

Other reason* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* If you have no specific reasons that comes to mind, we will more than likely find them when analyzing your hair.

HEREDITY IN YOUR MOTHER AND FATHER’S FAMILIES

Do the women tend to lose their hair?	yes	no
Do the men tend to lose their hair?	yes	no

STRESS

Do you think you are subject to stress?

yes

If yes : Punctually? Continuously?

Have you been through a psychological shock?

yes

If yes, approximately when?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HEALTH

Are you following a medical treatment?

yes

If yes, precisely what medication* do you take (read the names off the labels if needed)? . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Approximately for how long have you been taking the treatment? . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .
* Some drugs have a negative effect on hair reproduction, which is why we are asking.

Have you recently undergone major surgery?	yes	no
Are you following a strict weight-loss diet?	yes	no

If yes, since when approximately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

WOMEN ONLY: GYNECOLOGY

Do you take a hormonal contraceptive or substitution hormones?

yes

If yes, which one*? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .
* This question is important for our diagnosis because the hair is under hormonal dependence.

Do you wear an intrauterine device*?	yes	no
Are your menstruations very abundant?	yes	no
Is your period regular?	yes	no
Do you have any children younger than 1 year?	yes	no

How many childbirths or miscarriages have you been through? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .
* If your intrauterine device is hormonal, please specify so.

ANTI-HAIR LOSS TREATMENTS

Have you ever applied Minoxidil (an often prescribed anti-hair loss treatment)

yes

When and for how long? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .

Do you currently apply it?

yes

If yes , for how long approximately?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .

At what frequency ?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Another anti-hair loss treatment?

yes

If so , which one?. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

For how long approximately? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .

THE PROBLEMS THAT BOTHER YOU THE MOST:

The hair falls too much		It is dry
It is thinning out		very dry?
There is less hair		It is breaking
It is not growing well		very breaking?
It is greasy near the root		It has split ends
It is dull		It is difficult to comb
It is lifeless		It is difficult to untangle
It is porous		Dandruff
It is electrically charged		Itchiness

TWO TESTS: SCALP MOBILITY SUPPLENESS*

* Those tests will give indications on your blood circulation at scalp level.

1 - Lay your hands on your head, with the fingers slightly spread and the finger tips flat. Strongly press and try to make the scalp move along the skull, without your fingers slipping. Do you feel that it is:

Very mobile?
Mildly mobile?
Adherent ?

2 - Pinch your skin by firmly grabbing it between the thumb and the index by first placing your fingers on the forehead, where the skin is supple, then on the top of the head, where it usually is less so. If needed, return to the forehead, as a benchmark.

Is your hair supple?
Difficult to pinch?
Impossible to pinch?

Your age Your size Your weight

YOUR OBSERVATIONS

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Thank you for the information you have been willing to share with us. You will receive your In-Depth Clauderer Diagnosis report within a maximum of 20 days.

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Return to: Centre Clauderer, 346, rue Saint-Honoré 75001 Paris - Tel: +33 (0) 1 42 61 28 01

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