Unit 873 – Apply Light Cured Polish
Treatment Evidence Form
College Name:
College Number:
Learner Name:
Learner Number:
Date:
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):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
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
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
NAIL TEST:
Moisture content:
Excellent
Cuticle condition:
Excellent
Skin condition:
Dehydrated
Skin’s healing ability: Excellent
Circulation:
Good
Overall Nail/Skin condition:
Good
Good
Dry
Good
Normal
(select if/where appropriate):
Repetitive Strain Injury
Carpal Tunnel Syndrome
Severely bitten or damaged nails
Nail separation
Eczema
Psoriasis
Dermatitis
Loss of skin sensation
Chilblains
Corns
Verrucae
Wart(s)
Fair
Fair
Normal
Fair
Poor
Poor
Poor
Poor
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AREA TO BE TREATED:
Toe nails
Fingernails
Treatment details: (Including recommendations for removal)
Photographs – before and after:
Client Feedback:
Aftercare/Home care advice given:
Client’s Signature …………………………………
Learner’s Signature…………………….….……..
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