Client Consultation Form – Epilation
College Name:
College Number:
Student Name:
Student Number:
Date:
PERSONAL DETAILS
Age group: Under 20
20–30
Lifestyle: Active
Sedentary
Last visit to the doctor: 15/10/10
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
30–40
40–50
50–60
60+
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.
Cardiovascular conditions (thrombosis, phlebitis,
Multiple Sclerosis, Parkinson’s disease, Motor
hypertension, hypotension, heart conditions)
neurone disease)
Haemophilia
Neuralgia
Any condition already being treated by a GP or
Inflamed nerve
another practitioner
Cancer
Medical oedema
Spastic conditions
Nervous/Psychotic conditions
Whiplash and any neck conditions
Epilepsy
Slipped disc
Recent operations
Undiagnosed pain
Diabetes
When taking prescribed medication
Asthma
Endocrine disorders
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or
alcohol
Diarrhoea and vomiting
Mucous membranes
Hepatitis B
HIV/AIDS
Anti coagulant drugs
Bells Palsy
Loss of skin sensation
Keloid scarring
Skin diseases
Hairy moles
Undiagnosed lumps and bumps
Localised swelling
Inflammation
Hyper pigmentation
Botox/dermal fillers (1 week following treatment)
(select if/where appropriate):
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and 6
months for a small scar)
Sunburn
Hormonal implants
Abdomen (first few days of menstruation
depending how the client feels)
Haematoma
Hernia
Recent fractures (minimum 3 months)
Cervical spondylitis
Metal plates
Mechanical implants
WRITTEN PERMISSION REQUIRED BY:
GP/Specialist
Informed consent
Either of which should be attached to the consultation form
Version 3
Previous epilation treatment: No
Yes
diathermy per week on consultant referral
(if Yes for how long) 10 months 30mins session of
Result of previous treatment (if applicable): None noticed
Any skin reaction? Slight reddening of the area at the time of treatment
PRESENT HAIR AND SKIN CONDITION (select if/where appropriate):
Normal skin/Good healing
Erratic/Slow to heal
Sensitive/Prone to reaction
Dilated Capillaries Present
Oily & blocked
Scars Present
Subject to blemishes/Cysts
Strong/Pigmented Hair
Prone to pigmentation patches
Dense Fine Hair
Very dry skin
AREA OF TREATMENT (select if/where appropriate):
Face
Chest/breast
Bikini line
Abdomen
Underarms
METHOD OF TREATMENT (select if/where appropriate):
Short wave diathermy
Blend
Intensity used:
Machine used:
Treatment details to include possible reason for hair growth, hair type and reaction to treatment:
Client feedback:
After/Home care advice given:



Student’s/Therapist Signature................................................
Client’s Signature.....................................................................
Version 3