Client Consultation Form – Manicure & Pedicure
College Name:
College Number:
Student Name:
Student Number:
Date:
Client Name:
Address:
Profession:
Tel. No: Day
Eve
PERSONAL DETAILS
Age group: Under 20
20–30
Lifestyle: Active
Sedentary
Last visit to the doctor:
GP Address:
No. of children (if applicable):
Date of last period (if applicable):
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):
Haemophilia
Recent operations of the hands or feet
Any condition already being treated by a GP,
Diabetes
dermatologist or another practitioner
Inflamed nerve
Medical oedema
Undiagnosed pain
Arthritis
Acute rheumatism
Nervous/Psychotic conditions
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Abrasions
Infectious or contagious diseases
Scar tissues (2 years for major operation and 6
Under the influence of recreational drugs or
months for a small scar)
alcohol
Recent fractures (minimum 3 months)
Diarrhoea and vomiting
Sunburn
Any known allergies
Repetitive Strain Injury
Undiagnosed lumps and bumps
Carpal Tunnel Syndrome
Inflammation
Severely bitten or damaged nails
Cuts
Nail separation
Severe bruising
Eczema
Psoriasis
NAIL TEST
Moisture content
Cuticle condition
Skin condition
Skins healing ability
Circulation
Excellent
Excellent
Dehydrated
Excellent
Good
Good
Good
Dry
Good
Normal
Overall Nail/Cuticle condition:
Treatment to Include (select if/where appropriate):
Manicure
Pedicure
French polish
Fair
Fair
Normal
Fair
Poor
Poor
Poor
Poor
Details of treatment:
Client feedback:
Aftercare/Home care advice:
Student/Therapist Signature………………………………….
Client Signature…………………………………………………