Hair Examination Record Form
Please complete all sections to accurately record the results of the hair examination.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Examiner's Name
*
First Name
Last Name
Reason for Examination
*
Hair and Scalp Condition
*
Rows
Normal
Dry
Oily
Dandruff
Itchy
Thinning
Scalp
1
2
3
4
5
6
Hair Shaft
7
8
9
10
11
12
Hair Root
13
14
15
16
17
18
History of Hair or Scalp Treatments
Coloring
Bleaching
Chemical Straightening
Perming
Hair Extensions
Other
Current Hair Products or Medications Used
Observed Symptoms or Problems
*
Hair Loss
Breakage
Scalp Redness
Flaking
Itching
Other
Assessment or Diagnosis
*
Recommendations or Treatment Plan
Examiner's Signature
*
Submit Record
Submit Record
Should be Empty: