Please send the following information using the form below 

Send strand samples of your hair in a small zip lock bag. A picture of the damaged area (if balding is present) A brief letter to Mrs. Akbari telling her about your hair and scalp problems A self-addressed stamped envelope (No results will be returned without a stamped envelope) or e-mail address.  A day time and evening phone number and The completed questionnaire below

Questionnaire: Please Print

Name ______________________________________________ 

Address_____________________________________________ 

City_________________ State_______________   

Country_____________  Zip__________  Age:_________    

Race  Black_____ White_____ Hispanic ______ Other_________ 
Does a family member have a history of balding? yes____ no____ 
Mom_____  Dad_____ or other family member______________ 
Does any family member have a history of dry scalp or dandruff problems? yes__ no__ explain  _________________________________
Mom_ Dad__ or other family member_______________________ 
Do you have a chemical treatment in your hair? Yes ___ No __ permanent color_____ please explain type________________________ semi-  color/rinse _____ relaxer_____ Permanent wave_____  
How often is your hair chemically treated? ________________                       Is your hair Natural? Yes ____ No ____ If yes are you wearing? Braids___ Locks____ Twist ____ other please explain ______________________ How often is your hair shampooed? in salon _______ at home____
Hair Products used. salon/ professional_____________________________ over-the-counter_______________________________________________
When hair is styled, do your use a. blow-dryer ___,curling iron,__ wet set rollers,__ heat rollers, _____or other_______________________________ 
Do you sleep on a cotton pillow case ___, a satin pillow case ____, or other______________ 
Does your scalp? itch______ flake_______ feel tender to the touch_______ have bumps ___ Does your hair: break? (when you comb)_________ look dull_________ feel dry__________ 
When your hair is chemically treated, does your scalp: burn_____ tingle_____ or itch_____ 

Send in care of (SHS STUDIES)  

Please send the following information to the address below:

Lisa Akbari
Hair Nutrition and Research Clinic
1266 Sycamore View 105, Memphis TN 38134
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Send Check, Money Order, or Credit card

cost of strand reading is $39.00

         Visa,     Master Card,    American Express  or    Discover

                               underline one

Card Number__________________________ Expire _________