Uploaded by Suzannah Mercieca

facial consultation 2018-9

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Client Consultation Form
Client Name: ________________________
Date: ___________________
Address: ____________________________
Profession: _______________________
____________________________________
Tel. No:
Mobile_______________/Home___________
____________________________________
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): ________________________________
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
Any dysfunction of the nervous system (e.g.
Muscular sclerosis, Parkinson’s disease, Motor
Cardio vascular conditions (thrombosis, phlebitis,
neurone disease)
hypertension, hypotension, heart conditions)
Bells Palsy
Haemophilia
Trapped/Pinched nerve (e.g. sciatica)
Any condition already being treated by a GP or
another complementary practitioner
Inflamed nerve
Medical oedema
Cancer
Osteoporosis
Postural deformities
Arthritis
Spastic conditions
Nervous/Psychotic conditions
Kidney infections
Epilepsy
Whiplash
Recent operations
Slipped disc
Diabetes
Undiagnosed pain
Asthma
When taking prescribed medication
Acute rheumatism
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Sunburn
Contagious or infectious diseases
Hormonal implants
Under the influence of recreational drugs or
Abdomen (first few days of menstruation
alcohol
depending how the client feels)
Diarrhoea and vomiting
Haematoma
Skin diseases
Hernia
Undiagnosed lumps and bumps
Recent fractures (minimum 3 months)
Localised swelling
Cervical spondylitis
Inflammation
Gastric ulcers
Varicose veins
After a heavy meal
Pregnancy (abdomen)
Conditions affecting the neck
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and 6
months for a small scar)
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WRITTEN PERMISSION REQUIRED BY:
GP/Specialist
Informed consent
Either of which should be attached to the consultation form.
Skin Analysis
Skin:
Skin type:
Moisture
content:
Good/fair/poor
Oily
Skin
Conditions:
Sensitive
Muscle Tone:
Elasticity:
Sensitivity:
Circulation
Skin Tone:
Pores
Overall skin
type
Good/fair/poor
Good/fair/poor
High/Medium/low
Good/fair/poor
Fair/Medium/Dark
Tight/Dilated
Dry
Combination
Normal
Dehydrated
Young
Mature
Clients Concern
I hereby declare that the information given is the truth.
Client’s Signature…………………………………………………….
Learner’s/Therapist’s Signature...................................................
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Skin
Imperfections:
Broken
Capillaries
Pigmentation
Blemishes
Dark Circles
Comodones
Milia
TREATMENT PLAN
Treatment Aims
_____________________________________
Details of how the Therapist will be conducting the treatment:
_________________________________________________________________________________
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_________________________________________________________________________________
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_________________________________________________________________________________
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Details of how the client felt during the treatment:_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
____________________
Details of how the client felt after the treatment:_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
____________________
Details of home care advice given:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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____________________
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