Aromatherapy Client Intake Form
|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|
|___ 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:
|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:
|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:
|Do you have other symptoms or concerns that have not been covered?