This record tracks contraindication checks for advanced treatments on a per-visit basis. A new check must be completed at every appointment before treatment begins. Contraindications should be checked verbally and recorded with the date, therapist initials, and any notes. A clean check does not imply the same status at future visits.
Client Details
How to Use This Record
For each treatment session, complete the relevant treatment section below:
- Enter the date of the visit in the "Date" column
- Tick each contraindication row to confirm it was checked and does not apply (leave blank if not checked)
- Enter your initials in the "Init." column
- Record any contraindications identified, adaptations made, or reason treatment was deferred in "Notes"
- If a contraindication is present, circle it and record your action in Notes — do not proceed without resolution
| Contraindication to check |
Date |
Clear ✓ |
Init. |
Notes / action taken |
| Active acne lesions / open skin in treatment area | | | | |
| Rosacea / extreme sensitivity | | | | |
| Retinol / Vitamin A products (stop 2 weeks prior) | | | | |
| Recent waxing, laser, or IPL (within 2 weeks) | | | | |
| Recent Botox/fillers in treatment area (4 weeks) | | | | |
| Roaccutane / systemic acne medication (6+ months clear) | | | | |
| Pregnancy / breastfeeding | | | | |
| Known allergy to peel ingredients | | | | |
| Skin disorders — eczema, psoriasis, dermatitis in area | | | | |
| Sunburn / recent prolonged sun exposure | | | | |
| Contraindication to check |
Date |
Clear ✓ |
Init. |
Notes / action taken |
| Active acne / open pustules in treatment area | | | | |
| Blood-thinning medication | | | | |
| Keloid scarring history | | | | |
| Skin infection / cold sores / warts in area | | | | |
| Eczema / psoriasis / dermatitis in area | | | | |
| Recent Botox/fillers in area (4 weeks) | | | | |
| Roaccutane / high-dose Vitamin A (6+ months clear) | | | | |
| Pregnancy / breastfeeding | | | | |
| Diabetes (uncontrolled — slow healing) | | | | |
| Autoimmune condition / immunosuppressants | | | | |
| Contraindication to check |
Date |
Clear ✓ |
Init. |
Notes / action taken |
| Photosensitising medication (e.g. tetracyclines, NSAIDs, some antidepressants) | | | | |
| Epilepsy or photosensitive epilepsy | | | | |
| Active skin cancer or undergoing cancer treatment | | | | |
| Lupus / photosensitive autoimmune condition | | | | |
| Thyroid disorder (near-infrared near thyroid area) | | | | |
| Pacemaker (if treating chest area) | | | | |
| Pregnancy (first trimester, especially near abdomen) | | | | |
| Contraindication to check |
Date |
Clear ✓ |
Init. |
Notes / action taken |
| Pacemaker / cardiac device | | | | |
| Metal implants in or near treatment area | | | | |
| Epilepsy (galvanic current) | | | | |
| Diabetes (uncontrolled — poor healing) | | | | |
| Blood-thinning medication | | | | |
| Active infection / skin condition in treatment area | | | | |
| Pregnancy (avoid abdomen / lower back area) | | | | |
| Keloid scarring history | | | | |
| Contraindication to check |
Date |
Clear ✓ |
Init. |
Notes / action taken |
| Cardiovascular condition / hypertension (uncontrolled) | | | | |
| Diabetes (neuropathy — impaired sensation to heat) | | | | |
| Pregnancy (avoid abdomen) | | | | |
| Varicose veins / thrombosis risk | | | | |
| Inflammatory skin conditions / broken skin in area | | | | |
| Fever / acute illness | | | | |
| Recent surgery or injury in treatment area | | | | |
| Contraindication to check |
Date |
Clear ✓ |
Init. |
Notes / action taken |
| Active acne / pustules / inflamed cystic acne in area | | | | |
| Rosacea (active flush) | | | | |
| Cold sores / herpes simplex (active) | | | | |
| Flat moles / raised lesions / skin tags in treatment path | | | | |
| Blood-thinning medication | | | | |
| Retinol / AHA / BHA products used within 5 days | | | | |
| Roaccutane (must be 6+ months clear) | | | | |
| Eczema / psoriasis / dermatitis in treatment area | | | | |
| Sunburn / extreme sensitivity | | | | |
Ongoing Visit Log
Use the table below to log each subsequent visit check. Record the treatment given, date, any new contraindications raised, and therapist initials. Reference the specific treatment section above for the full check.
| Date |
Treatment given |
Any new contra? (Y/N) |
Notes / adaptations |
Init. |
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