|
Aromatherapy Client Intake Form |
| Full Name |
| Phone number |
| Mailing address |
| Birthdate |
| Reason for visit: What is your primary concern?
|
| Month/Year of onset of concern: Your idea of the cause:
|
| What makes it feel better? |
| What makes it feel worse? |
| Are you pregnant? Trying to become pregnant? Are you breastfeeding? |
| Chronic Conditions (please check) |
| ___ High Blood Pressure |
| ___ Low Blood Pressure |
| ___ Epilepsy |
| ___ Any seizure disorder other than epilepsy |
| ___ Allergies, please list: |
| Are you under the care of a physician? If so, please list the condition(s) you are being treated for:
|
| Medications: Please list all medications, herbs and supplements you are taking:
|
| Surgeries: Please list type and date of all surgeries:
|
| Social History |
| Do you drink coffee? How many cups a day? |
| Do you drink alcohol? How much per day? |
| What are your daily activities? |
| How many hours a night do you sleep? |
| Please provide any other information that you think we should know in order to treat you safely and effectively:
|
| Aroma questions |
| Are there particular scents or aromas that disturb you?
|
| Are there particular scents or aromas that you especially enjoy?
|
| Do you have allergic reactions to any scents? If so, which ones:
|
| Other concerns |
| Do you have other symptoms or concerns that have not been covered?
|
The Healing Place 