Treatment Evidence Form
Unit 851 – Apply Microdermabrasion
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):
Pregnancy
Diabetes
Cardiovascular conditions (thrombosis, phlebitis,
Asthma
hypertension, hypotension, heart conditions)
Bell’s Palsy
Haemophilia
Trapped/Pinched nerve
Any condition already being treated by a GP or
Inflamed nerve
Dermatologist
Cancer
Medical oedema
Spastic conditions
Osteoporosis
Undiagnosed pain
Nervous/Psychotic conditions
When taking prescribed medication
Epilepsy
Recent cosmetic or other surgery
Recent operations
Injections for personal enhancement
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or
alcohol
Diarrhoea and vomiting
Any known allergies
Skin cancer
Hepatitis
Skin diseases
Undiagnosed lumps and bumps
Hypersensitive skin
Broken capillaries
Localised swelling
(select if/where appropriate)
Inflammation
Cuts
Bruises
Abrasions
Scar tissue (2 years for major operation and 6
months for a small scar)
Sunburn
Haematoma
Recent fractures (minimum 3 months)
Any metal pins or plates
Loss of skin sensation (tactile test)
Botox/dermal fillers (1 week following
treatment)
SKIN TEST (select if/where appropriate):
Moisture content:
Excellent
Good
Fair
Poor
Muscle tone:
Excellent
Good
Fair
Poor
Elasticity:
Excellent
Good
Fair
Poor
Sensitivity:
High
Medium
Low
Skins healing ability: Excellent
Good
Fair
Poor
Skin tone:
Fair
Medium
Dark
Olive
Circulation:
Good
Normal
Poor
Pores:
Fine
Dilated
Comodones
Milia
OVERALL SKIN TYPE/CHARACTERISTICS (select if/where appropriate):
White
Black
Asian skin type
Mixed
Dry
Oily
Combination
Brief Description:
REASON/S FOR TREATMENT (select if/where appropriate):
Removal of: Comodones
Milia
Treatment of: Fine lines
Wrinkles
Scars
Lip lines
Mature
Young
Frown lines
Treatment details:
Client feedback:
After/Home care advice given:
Client Signature……………………………….……………
Learner Signature…………………………………………..
Unit 851 – Level 3 Apply Microdermabrasion – Treatment Evidence Form
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