Centre Clauderer WOMEN
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 bycredit card. You are unable to print the form? Just send us an email at info@clauderer.com. We will instantly post it out to you.
• Mrs
• Miss
• Full name (in capitals)
• 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
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
TICK the sketch(es) that best correspond(s) to the state of your hair (if needed, do not hesitate to modify them yourself)
TOP
top 1
top 2
top 3
top 4
SIDES
sides 1
sides 2
FRONT
front 1
front 2
front 3
YOUR SHAMPOOS
At least once a week
Three times a week
At least twice a week
Over three times a week
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
Do you use an anti-dandruff shampoo?
yes
no
Do you have a rash and dandruff on the sides of the face?
yes
no
Do you suffer from itchiness?
yes
no
Does your scalp sweat when you make a physical effort?
yes
no
HAIR LOSS
Does your hair currently fall more than it should?
yes
no
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
psychological shock
problems at work
illness (specify)
heredity
medical treatment
Other reasons (such as childbirth, miscarriage, abortion, menopause, nutrient deficiency. . .) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * 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
no
If yes : Punctually?Continuously?
HEALTH
Are you following a medical treatment?
yes
no
If yes, precisely what medication* do you take (read the names off the labels if needed)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* 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?
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.
credit card. 
