Client Consultation Form – Skin care and Eye Treatments

College Name: Elite School of Beauty Client Name: Roselyne Maswera

College Number: 1466 Address:      
Student Name:      
Student Number: Profession: student
Date:       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):      

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):
Medical oedema Skin cancer
Nervous/Psychotic conditions Slipped disc
Epilepsy Undiagnosed pain
Recent facial operations affecting the area When taking prescribed medication
Diabetes Whiplash

CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate)

Fever Hormonal implants
Contagious or infectious diseases Recent fractures (minimum 3 months)
Under the influence of recreational drugs or Sinusitis
alcohol Neuralgia
Diarrhoea and vomiting Sunburn
Any known allergies Migraine/Headache
Eczema Hypersensitive skin
Undiagnosed lumps and bumps Botox/dermal fillers (1 week following treatment)
Localised swelling Hyper-keratosis
Inflammation Skin allergies
Cuts Styes
Bruises Watery eyes
Abrasions Trapped/pinched nerve affecting the treatment
Scar tissues (2 years for major operation and 6 area
months for a small scar) Inflamed nerve
Sunburn Eye infection
Conjunctivitis

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:

Treatment to include (select if/where appropriate):

Superficial Cleanse Skin Analysis
Deep Cleanse Lash Tinting
Pre-Heat treatment Brow Tinting
Eyebrow Tweezing Mask
Massage

DECOLETE: NECK:
CHIN: LIPS &UPPER LIP:
L>CHEECK: R.CHEEK
NOSE: FOREHEAD:
SKIN COLOUR: EYES:
SKIN TONE: SKIN TYPE:
SKIN TEXTURE: MAIN OBJECTIVE:

CLIENT’S PROFILE
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Treatment Plan:
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Treatment details:
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Client Feedback:
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Aftercare/Home care advice given:

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Reflective practise:
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Therapist/student’s signature…………………………………………………..

Client’s signature………………………………………………………………….