Client Consultation Form – Apply Make-up College Name: College Number: Learner Name: Learner Number: Date: PERSONAL DETAILS Age group: Under 20 20–30 30–40 Lifestyle: Active Sedentary Last visit to the doctor: Can’t remember GP Address: No. of children (if applicable): 0 Date of last period (if applicable): 08/11 Client Name: Address: Profession: Tel. No: Day Eve 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): Medical oedema Skin cancer Nervous/Psychotic conditions Slipped disc Epilepsy Undiagnosed pain Recent facial operations affecting the area When taking prescribed medication Diabetes Whiplash CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate) Fever Hormonal implants Contagious or infectious diseases Recent fractures (minimum 3 months) Under the influence of recreational drugs or Sinusitis alcohol Neuralgia Diarrhoea and vomiting Sunburn Any known allergies Migraine/Headache Eczema Hypersensitive skin Undiagnosed lumps and bumps Botox/dermal fillers (1 week following treatment) Localised swelling Hyper-keratosis Inflammation Skin allergies Cuts Styes Bruises Watery eyes Abrasions Trapped/pinched nerve affecting the treatment Scar tissues (2 years for major operation and 6 area months for a small scar) Inflamed nerve Sunburn Eye infection Conjunctivitis 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 Skins healing ability: Excellent Good Fair Poor Skin tone: Fair Medium Dark Olive Circulation: Good Normal Poor Pores: Fine Dilated Comodones Milia Overall Skin Type: Normal Version 1 TREATMENT TO INCLUDE (select if/where appropriate): Day make-up Evening make-up Special occasion make-up Bridal Make-up Other: Treatment details: To include product/colours used, make-up chart and before and after photographs) Make-up Chart Pre-base: Concealer Corrective cream Foundation Powder Blusher Shader Highlighter Eye shadow Eye liner Mascara Lip liner Lipstick Lip gloss Version 1 Client feedback: Aftercare/homecare advice given: Learner’s signature………………………………………………. Client’s signature………………………………………............... Version 1