Docstoc

Client Consultation Form Manicure and Pedicure

Document Sample
Client Consultation Form Manicure and Pedicure Powered By Docstoc
					Client Consultation Form – Manicure & Pedicure
2011 version 4.1
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)
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:
Haemophilia                     Diabetes               Inflamed nerve
Recent operations to hands or feet                     Medical oedema
Any condition already being treated by a GP, dermatologist or another practitioner
Undiagnosed pain                Arthritis              Acute rheumatism
Nervous/psychotic conditions

CONTRAINDICATIONS THAT RESTRICT TREATMENT
Select if/where appropriate:
Infectious or contagious diseases                         Fever
Scar tissues (2 years for major operation, 6 months for a small scar)
Under the influence of recreational drugs or alcohol      Abrasions
Recent fractures (minimum 3 months)                       Diarrhoea and vomiting
Any known allergies              Sunburn                  Repetitive Strain Injury (RSI)
Undiagnosed lumps and bumps                               Carpel Tunnel Syndrome
Severely bitten or damaged nails                          Inflammation
Nail separation                  Severe bruising          Cuts
Eczema                           Psoriasis

NAIL TEST:
Moisture content:         Excellent     Good         Fair     Poor
Cuticle condition:        Excellent     Good         Fair     Poor
Skin condition:           Excellent     Good         Fair     Poor
Skin’s healing ability:   Excellent     Good         Fair     Poor
Circulation:              Good        Normal         Poor

Overall Nail/Cuticle condition:


Treatment to include
Select if/where appropriate:
Manicure         Pedicure         French polish
Details of treatment:


Client feedback:


After/Home care advice:


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


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




                        Manicure & Pedicure Case Study Form 2011 v 4.1
                                              2

				
DOCUMENT INFO