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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.
First Name
Last Name
Email
Address (include postcode)
Date of birth
Height
Phone
Weight
.
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
Allergies
Cancer
Dizziness
Epilepsy
Fainting
Headache
Mental disorder
Nervousness
Numbness
Arthritis
Upper back ache
Lower back ache
Broken bones
TMJ/Jaw pops
Mobility limitations
Spinal curvature
Sprained tendons/muscles
Stiff neck
Swollen joints
Belching
Bloating
Constipation
Diarrhea
Abdominal pain
Colitis
IBS
Crohn’s
Excessive urination
Water retention
Menopausal
Hot flashes
Mood swings
Irregular cycle
Breast lumps
Infertility
Vaginal discharge
Heart attack
Heart disease
High blood pressure
Low blood pressure
Pain in Heart Area
Poor circulation
Swelling of ankles/joints
Previous stroke
Asthma
Ear aches
Eye pains, Dry/Wet
Glaucoma
Sinus infections
Sore throat
Sinus congestion
Boils
Acne
Dry skin (lacking oil)
Dehydrated skin (lacking water)
Itching
Varicose veins
Inflamed/sensitive skin
Chest pain
Difficulty breathing
Dry cough
Spitting blood
Congestion
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