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Intake and consent form
This information will help to make the service tailored for your specific needs, but if you're not comfortable with any of the questions, just leave them blank.
Address (include postcode)
Date of birth
What are your goals and/or desired outcomes for incorporating aromatherapy into your plan of care?
What are your current health goals?
Do you have sensitive skin? If so, please list any issues you experience
Do you have any allergies or sensitivities to oils, lotions, scents, foods, medicine, plants, etc?
Do you frequently suffer from stress?
Please rate your level of stress with 10 = overwhelming and 1 = mild
Do you smoke? If so, how much in a day?
Do you have hypertension (high blood pressure)?
Are you currently receiving any treatment from a health ptractitioner? If so, for what reason?
Are you currently taking any medication? If so, which one(s) and for what reason?
Are you currently pregnant or breastfeeding?
How often do you exercise or engage in physical activity?
How much water do you drink in a day?
Do you currently feel overweight, underweight or at ideal weight?
On average, how many hours do you sleep each night?
Do you have difficulty falling asleep?
Please check any conditions that may apply to you
Upper back ache
Lower back ache
High blood pressure
Low blood pressure
Pain in Heart Area
Swelling of ankles/joints
Eye pains, Dry/Wet
Dry skin (lacking oil)
Dehydrated skin (lacking water)
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