Client Consultation Form – Skin Care, Eye Treatments Facial by rws17330

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									Client Consultation Form – Skin Care & Eye Treatments and
Facial Electrical Treatments
College Name:   The National School of Aesthetics             Client Name:
College Number: 1485                                          Address:
Student Name:
Student Number:                                               Profession:
Date:            01/01/2010                                   Tel. No:            Day:      (03) 123-4567
                                                                                  Night:    (03) 123-4567
PERSONAL DETAILS
Age group:       Under 20        20—30       30—40                       40—50             50—60            60+
Lifestyle:       Active       Sedentary
Last visit to the doctor:         01/01/2010
GP’s Name:
GP Address:
No. of children: (if applicable) 0
Date of last period: (if applicable)     01/01/2010

CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION
In circumstances where medical permission cannot be obtained, clients must give their
informed consent in writing prior to treatment.
Select if/where appropriate:

Recent operations               Diabetes                Nervous/psychotic conditions
Undiagnosed pain                Epilepsy                Taking prescribed medication
Medical oedema                  Skin cancer             Whiplash
Slipped disc                    Pregnancy               Haemophilia
                          1
Cardiovascular conditions       Acute Rheumatism        Bells Palsy
                                      2
Any dysfunction of the nervous system
Any condition already being treated by a GP or another practitioner
Trapped/pinched nerve           Inflamed nerve          Osteoporosis
Spastic conditions              Kidney infections       Asthma

CONTRAINDICATIONS THAT RESTRICT TREATMENT
Select if/where appropriate:

Hormonal implants                 Fever                    Sinusitis
Contagious or infectious diseases                          Diarrhoea and vomiting
Under the influence of recreational drugs or alcohol       Hypersensitive skin
Recent fractures (minimum 3 months)                        Localised swelling
Undiagnosed lumps and bumps                                Inflammation
Botox/dermal fillers (1 week following treatment)          Cuts
Bruises                           Abrasions                Sunburn
Neuralgia                         Any known allergies      Migraine/Headache
Eczema                            Hyper-keratosis          Skin allergies
Styes                             Watery eyes              Inflamed nerve
Scar tissues (2 years for major operation, 6 months for a small scar)
Trapped/pinched nerve affecting treatment area             Eye infection
Conjunctivitis
Haematoma                         Skin diseases            Cervical spondylitis
Any metal pins or plates          Loss of skin sensation (test with tactile test)


1
    Including, but not limited to, thrombosis, phlebitis, hypertension, hypotension and heart conditions
2
    Including, but not limited to, Muscular Sclerosis (MS), Parkinson’s Disease and Motor Neurone Disease
SKIN TEST
Select if/where appropriate:
Moisture content:        Excellent       Good    Fair   Poor
Muscle tone:             Excellent       Good    Fair   Poor
Elasticity:              Excellent       Good    Fair   Poor
Sensitivity:             High       Medium      Low
Skin’s healing ability: Excellent        Good    Fair   Poor
Skin tone:((Fitzpatrick)         Fair      Medium     Dark     Olive
Circulation:             Good         Normal     Poor
Pores:                   Fine      Dilated    Comodones      Milia

Overall Skin Type:

Treatment to include
Select if/where appropriate:
Manual Facial Treatments
Superficial Cleanse              Brow Tinting              Deep Cleanse
Pre-heat Treatment               Eyebrow Tweezing          Massage
Skin Analysis                    Mask                      Lash Tinting

Facial Electrical Treatments
Iontophoresis                    Microcurrent            Desincrustation
Vacuum Suction                   Faradism
Direct High Frequency            Indirect High Frequency




Client lifestyle/profile:




      Skin Care & Eye Treatments and Facial Electrical Treatments Case Study Form 2008 v 3.0
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Treatment plan and details:




Rationale for choice of electrical treatment:




How client felt during and after the treatment:




     Skin Care & Eye Treatments and Facial Electrical Treatments Case Study Form 2008 v 3.0
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Home care advice:




Reflective practice:




Overall conclusion:




Therapist’s/student’s signature:……………………………………………………………………


Client’s signature:…………………………………………………………………………………….




     Skin Care & Eye Treatments and Facial Electrical Treatments Case Study Form 2008 v 3.0
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