NVQB23 – Provide Indian Head Massage
Therapist Name
Date
VTCT Number
Portfolio number
Client Name
Assessment
Yes
No
Male / Female
New/ Existing
Standard
Summative
Formative
(past records checked)
IHLO4 ba,h,k,n IHLO5 c,h,i
IHLO6 c,k,l
IHLO6 c,k,l
Health & Safety check
General contra indication
Local contra indications
 Sterilised tools
May prevent full service
Service requiring adaption
 Hands sanitised
 Bacterial infection
 Recent scar tissue
 Area free from obstruction
 Viral infection
 Recent operation
 Adequate temperature
 Fungal infection
 Psoriasis
 Adequate lighting
 Parasitic infection
 Eczema
 Adequate ventilation
 Heart condition
 Materials disposed of in
 Diabetes
Temporary contra indications
accordance to H & S regulations
 Cancer
Service may require adaption
 Electrics checked
 High/low BP
 Medication
 products dispensed correctly
 Undiagnosed lumps
 Bruising
 Loss of skin sensation
 Skin abrasions
 Deep Vein Thrombosis
 Oedema
(DVT)
 During Chemo/Radio therapy
 Epilepsy
 Product allergies
 Rheumatism
 Pregnancy
IHLO6 d,e,n,o
Lifestyle Question and Analysis (Questioning)
Any medical history which may restrict or prohibit the service application?
Indicate any modification of treatment, or reasons why treatment could not be carried out:
Currently taking any medication which may affect the appearance of the skin or skin sensitivity?
Current dietary plan
Current fluid intake
Current Stress levels 1-4
Current exercise habits
Smoker?
Description of sleep patterns
Treatment objectives
 Relaxation
 Sense of well being
IHLO4 m IHLO11 e
Treatment Areas
 Face
 Scalp
 Shoulders
 Arms
 Neck
 Chakras
 Upper Back
Service Time
 45 mins
IHLO4 g,j
Pre treatment indemnity
signature; information is
correct at time of treatment:
--------------------------------
 Uplifting
Hair ‘Improvement
IHLO6 a,g,h,i,j
Physical Characteristics(Visual)
 Mesomorph
 Endomorph
 Ectomorph
 Posture checked
 Posture abnormalities present? ________
 scalp/hair condition
 skin type assessed
IHLO7 c IHLO10 a,b,c
Products Used (Manual)
 Sanitiser
Hair Oils used ____________________
Reason for use _______________________
IHLO6 f,n,o IHLO12 a-e
After Care Advice
 Healing crisis
 Recommended time intervals between services
 Importance of a course of service to improve
the skin condition.
 Modification of lifestyle patterns
 Healthy eating and exercise advice
Equipment Used
 Consumables
IHLO11 h,i
Massage Techniques
 Effleurage
 Petrissage
 Tapotement
 Vibrations
 Frictions
Retail Opportunities
 Products suitable to use at home
 Progression of service plan
 New product or service offered to the client
IHLO11 n
Client Evaluation e.g. polite, professional, capable. Explanation of treatment good/not enough. Please
feel free to put any comments down about the salon, therapist and treatments to enable us to provide a
good service. Thank you.
Client Signature
Therapist self evaluation
The technique I can do well is:
Date
I feel I need to improve on:
The products I recommended were:
This is because:
Did they buy the recommended product? Yes/ No
I encourage my client to rebook for:
This is because:
Did they rebook with you? Yes/ No
Therapist Signature
Assessor Feedback
Oral questions asked relating to:
 H & S  C.I’s  Routine
Assessor Signature
Date
Products
Date
 Home care
 C.A’s
 Consultation