Client Consultation Form Skin care and Eye Treatments

College Name: College Number: Student Name: Hanadi Yousif Student Number: Date: Client Name: Shikha Al kawari Address: Profession: Tel. No: Day Eve

PERSONAL DETAILS Age group: Under 20 2030 3040 Lifestyle: Active Sedentary Last visit to the doctor: last 2 day GP Address: No. Of children (if applicable): Date of last period (if applicable):

4050

5060

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): 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 Deep Cleanse Pre-Heat treatment Skin Analysis Lash Tinting

Brow Tinting Eyebrow Tweezing Massage Mask

Treatment details: consultation form- eye and lip cleanse- pre cleans super ficial cleans- 2nd cleans wich one- tone- skin analysis- steam for how long- extractions- brush cleans using acleansing creamtone- massage almnd oil- tone- mask wich ones- painted nails while setting tone- moisturise- eye cream- home care advice (To include products used) Client Feedback: Aftercare/Home care advice given:

Therapist/students signature HANADI.. Clients signatureSHIKHA.