Scalp Intake Form – Alani Massage Therapy, Reiki, & Head Spa

Client Questionnaire and Consent form

Name

First

Last

1. How would you describe your scalp?

2. How do you describe your scalp type? (Oily, Normal, Dry, Combination – Oily Scalp & Dry Ends)

3. Are you currently experiencing any of the following scalp disorders? (Excessive Oiliness, Dryness or Flakiness, Itchiness, Scalp Eczema, Scalp Psoriasis, Dandruff, Hair Loss)

4. Do you experience any scalp discomfort when touching your scalp? (Yes / No)

touching Ends) ever

5. What products are you currently using? Please specify brands (shampoo, conditioner, masks, styling products).

6. Do you double cleanse?

7. How often do you wash your hair?

8. Have you had any color or chemical services (e.g., color, bleach, relaxer, perm, keratin, henna) in the past 2 weeks, or do you plan to receive one within the next 2 weeks? If yes, please describe and include the date.

9. Did the color or chemical service take place in a salon or at home? (Salon / Home)

10. Have you ever had a scalp treatment before? If yes, when was the last one?

11. Which type of water do you have at home? (Hard Water/Well Water, Soft Water)

12. Please list any medication you are taking, including vitamins.

13. Have you been under anesthesia or on antibiotics in the last 6 months? (Yes / No). If yes, please specify:

14. Do you have any allergies? Please list them below.

15. Are you sensitive to any specific ingredients (e.g., essential oils, sulfates, parabens)? (Yes / No). If yes, please specify:

16. Do you believe your lifestyle (stress, diet, etc.) may be contributing to your scalp or hair concerns? (Yes / No). If yes, please specify:

17. How would you describe your diet? (vegan, vegetarian, pescatarian, omnivorous)

18. How often do you consume the following? (Alcohol, Dairy, Gluten, Sugar)

19. Have you noticed any sudden changes in your hair or scalp in the last few months? (Yes / No). If yes, please describe:

20. When was the last time you had bloodwork done? Including thyroid panel and vitamins check.

21. Please provide us with any additional concerns or hair goals for your visit to:

Client Consent & Disclaimer

I agree to the following terms.

I confirm that the information provided above is accurate to the best of my knowledge. I understand that the services provided by Alani Massage Therapy, Head Spa and Reiki are not a substitute for medical treatment or diagnosis. Teresa Jones is a trained scalp and holistic therapist, but is not a licensed medical provider and cannot diagnose or prescribe treatment for medical conditions. All recommendations are based on professional training, experience, and current best practices in scalp and hair wellness.