Unit 817 – Provide Ear Piercing
Treatment Evidence Form
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:
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
40–50
Have your ears been pierced previously? No
50–60
Yes
CONTRAINDICATIONS (select if/where appropriate):
Fever
Any form of infectious disease
Under the influence of recreational drugs or alcohol
Diarrhoea and vomiting
Cuts and abrasions to the ear/lobe
Bruises to the ear/lobe
Inflammation to the ear/ lobe
Moles on the ear/lobe
Warts on the ear/lobe
Scar tissue (2 years for major operation and 6 months
for a small scar)
Severe skin conditions
60+
If yes how long ago:
Diabetes
Keloid scar tissue
Ear infection
Cardio-vascular conditions
Dysfunction of the nervous system
Nervous/Psychotic conditions
Allergies to metals
Epilepsy
Bell’s Palsy
Inflamed nerve of the face, head or ear
Recent operations on the face, head, neck or ear
Recent injury to the ear/lobe
Treatment details:
(To include photographic evidence)
Client feedback:
After care/home care advice given:
Client Signature……………………………………………...
Learner Signature……………………………………………
Parent/Guardian Signature (if under 16 years of age)…………………………………………….
Unit 817 - Provide Ear Piercing
Treatment Evidence Form
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