College Name:
College Number:
Learner Name:
Client Name:
Address:
Learner Number:
Date:
Profession:
Tel. No: Day
Eve
PERSONAL DETAILS
Age group: Under 20 20 –30 30 –40 40 –50 50 –60 60+
Lifestyle: Active Sedentary
Last visit to the doctor:
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
Have your ears been pierced previously?
No Yes If yes how long ago:
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
Diabetes
Keloid scar tissue
Ear infection
Cardio-vascular conditions
Dysfunction of the nervous system
Nervous/Psychotic conditions
Inflammation to the ear/ lobe
Moles on the ear/lobe
Warts on the ear/lobe
Allergies to metals
Epilepsy
Bell’s Palsy
Scar tissue (2 years for major operation and 6 months Inflamed nerve of the face, head or ear for a small scar)
Severe skin conditions
Recent operations on the face, head, neck or ear
Recent injury to the ear/lobe
Treatment details:
(To include photographic evidence)
Provide Ear Piercing Treatment Evidence Form 1

Client feedback:
After care/home care advice given:
Pass
Refer
Assessor’s Signature..................................................... Client’s Signature……………………………
Internal Verifier’s Signature........................................... Learner’s signature…………………………
External Verifi er’s Signature .........................................
Parent/Guardian Signature (if under 16 years of age)…………………………………………….
Provide Ear Piercing Treatment Evidence Form 2