MTUV74 – Provide Indian Head Massage

Therapist Name / Date
VTCT Number / Portfolio number
Client Name / Assessment / Yes / No
Male / Female New/ Existing
(past records checked) / Standard / Summative / Formative
Health & Safety check
 Sterilised tools
 Hands sanitised
 Area free from obstruction
 Adequate temperature
 Adequate lighting
 Adequate ventilation
 Materials disposed of in accordance to H & S regulations
 Electrics checked
Products dispensed correctly
Follow professional Ethics / General contra indication
May prevent full service
 Bacterial infection
 Viral infection
 Fungal infection
 Parasitic infection
Heart condition
 Diabetes
 Cancer
 High/low BP
 Undiagnosed lumps
 Loss of skin sensation
 Deep Vein Thrombosis (DVT)
 Epilepsy
 Rheumatism / Local contra indications
Service requiring adaption
 Recent scar tissue
 Recent operation
 Psoriasis
 Eczema
Temporary contra indications
Service may require adaption
 Medication
 Bruising
 Skin abrasions
 Oedema
 During Chemo/Radio therapy
 Product allergies
 Pregnancy
IHMLO1g
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
IHMLO2p
Pre treatment indemnity signature; information is correct at time of treatment:
------
Current exercise habits
Smoker?
Description of sleep patterns
Treatment objectives
 Relaxation  Sense of well being  Uplifting Hair ‘Improvement
IHMLO1e
Treatment Areas
 Face  Scalp
 Shoulders  Arms
 Neck  Chakras
Upper Back
Service Time
 45 mins / IHMLO1h
hysical Characteristics(Visual)
 Mesomorph
 Endomorph
 Ectomorph
 Posture checked
 Posture abnormalities present? ______
scalp/hair condition
skin type assessed
IHMLO1i
Products Used (Manual)
Sanitiser
Hair Oils used ______
Reason for use ______/ Equipment Used
Consumables
IHMLO2k
Massage Techniques
 Effleurage
 Petrissage
 Tapotement
 Vibrations
 Frictions
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
Retail Opportunities
 Products suitable to use at home
 Progression of service plan
 New product or service offered to the client
IHMLO2o
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 Date
IHMLO2q
Therapist self evaluation
The technique I can do well is:
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 Date
Assessor Feedback
Oral questions asked relating to:
 H & S  C.I’s  Routine Products  Home care  C.A’s  Consultation
Assessor Signature Date