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Taking a client history

Recording a client's needs and conditions before a treatment. Process only: no medical advice.

about this course

What you will be able to do

L3 FoundationAbout 2 hours (120 minutes) of CPDSelf-study plus role-playBeauty and complementary therapies

Recording a client's needs and conditions before a treatment. Process only: no medical advice.

  • Collect client information, given a form, with every required field complete.
  • Identify a reason not to proceed, given 8 sample histories, with at least 7 correct and referral to the right person.
  • Record consent, given a template, with date, signature and what was agreed.
  • Protect client privacy, given a sample, storing the form safely.

Task, condition and standard

Task

Take a client history before a treatment by asking the required questions in order, recording the answers dated and signed, and deciding whether to proceed or refer on.

Condition

Given a history form, a referral card, eight sample histories and a role-play client, working in a two-hour supervised session; process only, with no medical advice.

Standard

Produce a form complete in all 9 fields, answers dated and signed, at least 7 of 8 sample histories decided correctly, and the form stored securely.

These courses teach process, communication and recording. They give no clinical, legal, tax, financial or engineering sign-off. A named subject expert must review every line, and you must check your own professional body's current CPD rules, before you rely on a certificate.

sessions

8 modules

Module 1 Why history matters 15 min
  • A history protects the client from harm
  • It proves what was asked and answered
  • Take it before every new treatment
Worked example. Case card: a client reports a skin rash and a new medicine. The history protects the client: the rash and the medicine are both reasons to check before any treatment. The answers are written down with the date so they can be shown later.

Practise: Practise with a case card or template for "why history matters": collect client information, given a form, with every required field complete.

Standard to meet. Explain why a client history is taken before treatment, naming how it protects the client from harm and why it is recorded.

Module 2 Required questions in order 25 min
  • Ask the required questions in order
  • Use plain, kind wording
  • Leave no field blank
Worked example. The form has 9 fields in order: name, contact, reason for visit, allergies, skin conditions, medicines, pregnancy, previous reactions, consent to record. 5 are health questions (allergies to previous reactions) and 4 are admin, so 5 + 4 = 9.

Practise: Practise with a case card or template for "required questions in order": identify a reason not to proceed, given 8 sample histories, with at least 7 correct and referral to the right person.

Standard to meet. Apply the required history questions in order, covering allergies, skin conditions, medicines, pregnancy and previous reactions, so every required field is complete.

Module 3 Recording clearly 20 min
  • Date and sign every record
  • Record a refusal
  • Keep the form secure; share only with consent
Worked example. Entry: "14 Jun. Pregnancy: client declined to answer. Treatment paused until the referral card is checked. Signed client, signed therapist." Date, answer, refusal and both signatures are present. The form is kept in a locked cabinet.

Practise: Practise with a case card or template for "recording clearly": record consent, given a template, with date, signature and what was agreed.

Standard to meet. Record a client's answers clearly on the form, dated and signed, and note any refusal to answer, while keeping the form secure.

Module 4 When to refer on 25 min
  • Refer when it is beyond your scope
  • Refer when it is unsafe to proceed
  • Record the referral
Worked example. 8 sample histories, 7 correct needed, which is 7 of 8 or 87.5%. A learner who gets 6 right has 75%, below the standard, and revisits the referral card. Reasons to refer on the sample card include a new medicine with a rash and recent surgery.

Practise: Practise with a case card or template for "when to refer on": protect client privacy, given a sample, storing the form safely.

Standard to meet. Identify from sample histories the reasons not to proceed and refer the client on to the right person, with at least 7 of 8 correct.

Module 5 Role-play 10 min
  • Ask a follow-up for each warning sign
  • Do not give medical advice
  • Decide: proceed or refer on
Worked example. Role-play: a client mentions recent surgery. Follow-up questions: "When was it?" "Has your doctor said you can have this treatment?" "Any redness or healing still going on?" Decision: refer on, and record it.

Practise: Practise with a case card or template for "role-play": protect client privacy, given a sample, storing the form safely. Use a new case this time (round 2).

Standard to meet. Demonstrate taking a history in a role-play with a client who mentions recent surgery or a skin condition, asking follow-up questions and deciding on referral.

Module 6 Check 5 min
  • Complete the form for a case card
  • Decide correctly
  • Store the form securely
Worked example. Check: case card with rash and new medicine. Form 9 of 9 fields complete, dated and signed. Decision: refer on, because the referral card says a rash with a new medicine is not for the therapist to judge. 1 of 1 decisions correct.

Practise: Take the end check for "taking a client history": show that you can protect client privacy, given a sample, storing the form safely, and meet every outcome standard above.

Standard to meet. Apply the history form to a case card by completing it and deciding correctly whether to proceed or refer on.

Module 7 Second case: surgery and a skin condition 10 min
  • A client with two warning signs
  • Ask follow-ups for each
  • Decide and record
Worked example. Case card 2: a client had surgery 3 weeks ago and has a skin condition. Two warning signs, 2 follow-up questions each = 4 questions. Decision: refer on and record the reason, date and signature.

Practise: Practise with a case card or template for "second case: surgery and a skin condition": protect client privacy, given a sample, storing the form safely. Use a new case this time (round 2).

Standard to meet. Apply the history questions to a client with two warning signs, ask follow-up questions for each, and decide whether to proceed or refer on.

Module 8 Updating at each visit and reflection 10 min
  • Ask what has changed
  • Date every update
  • Reflect on your question order
Worked example. A client returns at weeks 0, 4 and 8, so there are 3 visits and 3 dated updates. At week 4 a new medicine is noted, and the therapist checks the referral card before any treatment.

Practise: Practise with a case card or template for "updating at each visit and reflection": protect client privacy, given a sample, storing the form safely. Use a new case this time (round 2).

Standard to meet. Update a history at each visit by asking what has changed, record it dated and signed, and reflect on how to improve your questioning.

practice

Worked example and case cards

Worked example fields

name; contact; reason for visit; allergies; skin conditions; medicines; pregnancy; previous reactions; consent to record. Referral rule: if a condition is outside scope, refer on and record it.

Case card

a client reports a skin rash and a new medicine.

Case card 2

A client mentions recent surgery and a skin condition. Learners ask follow-ups and decide referral.

checks

10 check questions with model answers

Why ask about allergies?

Model answer: To avoid harm. (Covered in module 1: Why history matters. To pass that module: Explain why a client history is taken before treatment, naming how it protects the client from harm and why it is recorded.)

When refer on?

Model answer: When it is beyond your scope or unsafe to proceed. (Covered in module 4: When to refer on. To pass that module: Identify from sample histories the reasons not to proceed and refer the client on to the right person, with at least 7 of 8 correct.)

Privacy?

Model answer: Keep the record secure; share only with consent. (Covered in module 3: Recording clearly. To pass that module: Record a client's answers clearly on the form, dated and signed, and note any refusal to answer, while keeping the form secure.)

Date and sign?

Model answer: Yes, every record. (Covered in module 3: Recording clearly. To pass that module: Record a client's answers clearly on the form, dated and signed, and note any refusal to answer, while keeping the form secure.)

Why date and sign?

Model answer: Proof of when and by whom. (Covered in module 3: Recording clearly. To pass that module: Record a client's answers clearly on the form, dated and signed, and note any refusal to answer, while keeping the form secure.)

What if a client skips a question?

Model answer: Record the refusal; do not treat until it is checked against the referral card. (Covered in module 3: Recording clearly. To pass that module: Record a client's answers clearly on the form, dated and signed, and note any refusal to answer, while keeping the form secure.)

When refer?

Model answer: Per the referral card, such as medical conditions. (Covered in module 4: When to refer on. To pass that module: Identify from sample histories the reasons not to proceed and refer the client on to the right person, with at least 7 of 8 correct.)

Who sees the form?

Model answer: Only those who need it. (Covered in module 3: Recording clearly. To pass that module: Record a client's answers clearly on the form, dated and signed, and note any refusal to answer, while keeping the form secure.)

How often update?

Model answer: At each visit for changes. (Covered in module 8: Updating at each visit and reflection. To pass that module: Update a history at each visit by asking what has changed, record it dated and signed, and reflect on how to improve your questioning.)

A history form has 9 required fields and a client has answered 7. How many are missing, and what do you do before treatment?

Model answer: 2 are missing. Ask for them, or record the refusal, and follow the referral card before going ahead. (Covered in module 2: Required questions in order. To pass that module: Apply the required history questions in order, covering allergies, skin conditions, medicines, pregnancy and previous reactions, so every required field is complete.)

glossary

Words used in this course

history, contraindication, referral, confidentiality, update.

marking

How the practice and assessment are marked

LevelMeaningMarks of 4
SecureMeets the standard in the outcome every time, no prompts4
MeetingMeets the standard with one small slip, corrected when prompted3
DevelopingMeets part of the standard; needs a re-attempt2
Not yetStandard not met1

Pass = average 3 or more, and no outcome at 1. You may re-attempt after feedback. The subject expert sets any stricter pass mark.

where next

Ladder L1 to L7, slide by slide with notes

  1. Slide 1: L1 Basic: What is a client history. Speaker note: A client history is a short form of questions asked before a treatment. At this level the learner knows that it keeps the client safe and must be dated and signed.
  2. Slide 2: L2 Awareness: The required questions. Speaker note: Show the nine fields from name to consent to record. The learner at this level can name the health questions, such as allergies and medicines, and say why each one is asked.
  3. Slide 3: L3 Foundation: Taking and recording. Speaker note: Learners ask the questions in order from a script, under supervision, and record answers dated and signed. They practise noting a refusal and following the referral card for simple cases.
  4. Slide 4: L4 Practitioner: Take a history and decide. Speaker note: This course sits here. The learner takes a full history alone, completes all nine fields, spots warning signs in sample histories, decides to proceed or refer on, and stores the form securely.
  5. Slide 5: L5 Specialist: Complex histories. Speaker note: The specialist handles clients with several warning signs, such as surgery and a skin condition, asks careful follow-ups, and coaches new staff. They never give medical advice and refer on at once when needed.
  6. Slide 6: L6 Advanced: Standards for the whole salon. Speaker note: The advanced worker designs the form and referral card, audits histories for missing fields and signatures, and reports trends. Talk about how often updates at each visit are really done.
  7. Slide 7: L7 Super expert: A client safety system. Speaker note: The super expert designs the history and referral system for a group of salons: forms, privacy rules, training and measures such as complete forms per month. They prove it works with audits.

This course sits at L3 Foundation. Credits stack; aligned with, not accredited by, any framework.

jobs this leads to

Where this takes you

  • Beauty therapist
  • Salon receptionist
  • Spa assistant
  • Nail technician
  • Complementary therapy assistant

assessment and certificate

How you are checked

Each outcome is checked against its standard with a checklist or a short test. A digital CPD record shows the hours. Keep evidence in My page. Aligned with common CPD practice; not accredited. Learners check their own body's rules.

ten locations and global

Your place

Use your own body's forms, units and currency. Local professional bodies set the rules for CPD hours; check them first.

India (Bengaluru)

Language: English, Hindi, Kannada. Personal data: Digital Personal Data Protection Act 2023. Credit and levels: National Skills Qualifications Framework (NSQF) and the national credit framework.

Netherlands (Eindhoven area)

Language: Dutch, English. Personal data: EU GDPR (Dutch: AVG), supervised by the Autoriteit Persoonsgegevens. Credit and levels: the Dutch qualification framework (NLQF) linked to the European Qualifications Framework.

UAE (Dubai and Abu Dhabi)

Language: Arabic, English. Personal data: Federal Decree-Law No. 45 of 2021 (personal data protection). Credit and levels: the emirate education and training regulators (for example KHDA in Dubai) and the national qualifications framework.

Brazil (Sao Paulo)

Language: Portuguese (Spanish and English support). Personal data: LGPD (Lei Geral de Protecao de Dados). Credit and levels: the national technical-education catalogue and the national S-system training bodies.

Canada (Toronto)

Language: English, French. Personal data: PIPEDA, with provincial rules where they apply. Credit and levels: the provincial colleges framework and the national credential-recognition guidance.

United States

Language: English, Spanish. Personal data: state privacy laws (for example California), and COPPA for children under 13. Credit and levels: state and community-college credit systems.

Singapore

Language: English, Mandarin, Malay, Tamil. Personal data: Personal Data Protection Act (PDPA). Credit and levels: the Singapore national skills frameworks and the national credit system.

Australia

Language: English. Personal data: the Privacy Act 1988 and the Australian Privacy Principles. Credit and levels: the Australian Qualifications Framework (AQF) levels.

Hong Kong (Eastern Asia)

Language: Chinese (Cantonese, Mandarin), English. Personal data: the Personal Data (Privacy) Ordinance. Credit and levels: the Hong Kong Qualifications Framework.

Georgia and Israel (Western Asia)

Language: Georgian, Hebrew, Arabic, English. Personal data: the personal data law of the country where the learner lives. Credit and levels: the national qualifications framework of that country.

Cayman Islands (Caribbean)

Language: English. Personal data: the Data Protection Act. Credit and levels: the local education and training framework.

Mexico

Language: Spanish, English. Personal data: the federal law on personal data held by private parties. Credit and levels: the national competency certification system and the education ministry levels.

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