Scalp & Hair Health Assessment sponsored by Royal Revival®, Randburg, South Africa

Thank you for taking the time to complete this online assessment.

Its purpose is to support education and early awareness of your scalp and hair health, helping you better understand your needs.

By completing this form, you consent to your information being collected and used in line with the Protection of Personal Information Act (POPIA). Your information will be kept confidential and will not be shared with third parties.

To share the outcome of your assessment, including personalised, Practitioner-Led guidance, we do require an email address.

If you have any questions or need support, please feel free to contact us at info@royalrevival.co.za or 083 307 2266 - we're happy to help.

Your Information

Full Name *

Email Address *

Telephone Number If you would like for us to call you, kindly leave your cellular number.

Survey Questions

Where are you noticing changes, thinning, or shedding? (Select all that apply)

Understanding where changes occur helps guide appropriate care. Some patterns can be supported through scalp care and routine education, while others may require medical assessment.

Hairline / Edges Crown / top of scalp Diffuse (overall thinning or breaking across the scalp) Patches or localised areas I am struggling with dry, grey hair Unsure

Hair Loss Pattern

Have you noticed sudden or patchy hair loss?

Sudden shedding Patchy hair loss Gradual thinning No hair loss

How long have you been experiencing your current concern?

Less than 3 months 3–6 months 6–12 months Over 1 year Unsure

Which styles do you wear regularly? (Tick all that apply) (Select all that apply)

Braids Cornrows Locs Wigs / Weaves Tight ponytails / buns Heat styling Relaxed Hair Natural loose styles I dont have hair, I wear a doek Straight hair (short, medium, long length)

Common Scalp Concerns - Which best describes your current scalp concern? (Choose all that apply) (Select all that apply)

Dry or tight scalp Mild flakes Itch that improves after washing Product build-up Occasional sensitivity Oily scalp Oily scalp but dry ends on my hair I don't know what routine to follow None of the above

Scalp Integrity - Have you noticed any of the following on your scalp? (Choose all that apply) (Select all that apply)

Open sores Oozing, pus, or bleeding Thick crusts or scabs None of the above

Pain & Inflammation - Do you experience pain, burning, or severe tenderness on your scalp?

Yes No Maybe Yes and diagnosed by a medical professional before

How often do you moisturise or hydrate your hair and scalp with oils, cream, gels?

Daily 2–3 times per week Weekly Rarely Not sure how often

Hair Texture

What is your hair texture?

Wavy/Curly Coily / Kinky Mixed textures Straight Not sure

Age Group

What is your age?

18-24 25-34 35-44 45-54 55+

Additional Information

Is there something else you would like to bring to my attention? (Optional)