Provide Pedicure Treatments
Treatment Evidence Form
College Name:
College Number:
Learner Name:
Learner Number:
Date:
Client Name:
Address:
Profession:
Tel. No: Day
Eve
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):
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
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Fever
Infectious or contagious diseases
Under the influence of recreational drugs or
alcohol
Diarrhoea and vomiting
Any known allergies
Undiagnosed lumps and bumps
Inflammation
Cuts
Severe bruising
Abrasions
Scar tissue (2 years for major operation and 6
months for a small scar)
Recent fractures (minimum 3 months)
Sunburn
(select if/where appropriate):
Repetitive Strain Injury
Carpal Tunnel Syndrome
Severely bitten or damaged nails
Nail separation
Eczema
Psoriasis
Loss of skin sensation
Chilblains
Corns
Verrucae
Wart(s)
DISEASES AND DISORDERS (select if/where appropriate):
Beau’s line
Discoloured nails
Hang nail(s)
Mould
Onychocryptosis
Onychophagy
Onychorrhexis
Pterygium
Transverse ridges
Blue nail
Eczema
Koilonychia
Onychatrophia
Onychogryphosis
Onychophyma
Paronychia
(Whitlow)
Vertical ridges
Provide Pedicure Treatments - Treatment Evidence Form
Bruised nail(s)
Flaking
Lamella dystrophy
Onychauxis
Onycholisis
Onychoptosis
Pitting
Sepsis
Dermatitis
Habit tic
Leuconychia
Onychia
Onychomycosis
(Tinea Ungium)
Psoriasis
Severely bitten/
picked skin around
the nail
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NAIL TEST:
Moisture content
Cuticle condition
Skin condition
Skin’s healing ability
Circulation
Excellent
Excellent
Dehydrated
Excellent
Good
Good
Good
Dry
Good
Normal
Fair
Fair
Normal
Fair
Poor
Poor
Poor
Poor
Overall skin/nail condition:
Treatment (select if/where appropriate):
Pedicure
Foot and Nail Treatments:
Paraffin wax
Nail finishes:
Dark varnish
Foot mask
Thermal boots
Exfoliants
Light varnish French varnish
Treatment details:
Client feedback:
Home care advice:
Pass
Refer
Assessor’s Signature.....................................................
Client’s Signature……………………………
Internal Verifier’s Signature...........................................
Learner’s signature…………………………
External Verifier’s Signature .........................................
Provide Pedicure Treatments - Treatment Evidence Form
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