Client Consultation Form Client Name: ________________________ Date: ___________________ Address: ____________________________ Profession: _______________________ ____________________________________ Tel. No: Mobile_______________/Home___________ ____________________________________ PERSONAL DETAILS Age group: Under 20 20–30 30–40 40–50 50–60 60+ Lifestyle: Active Sedentary Last visit to the doctor: _________________________________________ GP Address: __________________________________________________ No. of children (if applicable): ___________________________________ Date of last period (if applicable): ________________________________ 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): Pregnancy Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor Cardio vascular conditions (thrombosis, phlebitis, neurone disease) hypertension, hypotension, heart conditions) Bells Palsy Haemophilia Trapped/Pinched nerve (e.g. sciatica) Any condition already being treated by a GP or another complementary practitioner Inflamed nerve Medical oedema Cancer Osteoporosis Postural deformities Arthritis Spastic conditions Nervous/Psychotic conditions Kidney infections Epilepsy Whiplash Recent operations Slipped disc Diabetes Undiagnosed pain Asthma When taking prescribed medication Acute rheumatism CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate): Fever Sunburn Contagious or infectious diseases Hormonal implants Under the influence of recreational drugs or Abdomen (first few days of menstruation alcohol depending how the client feels) Diarrhoea and vomiting Haematoma Skin diseases Hernia Undiagnosed lumps and bumps Recent fractures (minimum 3 months) Localised swelling Cervical spondylitis Inflammation Gastric ulcers Varicose veins After a heavy meal Pregnancy (abdomen) Conditions affecting the neck Cuts Bruises Abrasions Scar tissues (2 years for major operation and 6 months for a small scar) V3 WRITTEN PERMISSION REQUIRED BY: GP/Specialist Informed consent Either of which should be attached to the consultation form. Skin Analysis Skin: Skin type: Moisture content: Good/fair/poor Oily Skin Conditions: Sensitive Muscle Tone: Elasticity: Sensitivity: Circulation Skin Tone: Pores Overall skin type Good/fair/poor Good/fair/poor High/Medium/low Good/fair/poor Fair/Medium/Dark Tight/Dilated Dry Combination Normal Dehydrated Young Mature Clients Concern I hereby declare that the information given is the truth. Client’s Signature……………………………………………………. Learner’s/Therapist’s Signature................................................... V3 Skin Imperfections: Broken Capillaries Pigmentation Blemishes Dark Circles Comodones Milia TREATMENT PLAN Treatment Aims _____________________________________ Details of how the Therapist will be conducting the treatment: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________ Details of how the client felt during the treatment:_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________ Details of how the client felt after the treatment:_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________ Details of home care advice given: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________ V3
