CLIENT CONSULTATION FORM

CLIENT CONSULTATION FORM
The purpose of this consultation is not to diagnose any condition or health issues you may have but to identify your current state of health and what product(s) or treatments may be useful in dealing with a diagnosed condition or health issue. If you require a diagnosis, please consult your doctor or another appropriately qualified professional person
Name
Date of Birth: Age

MonthDayYear
Date
Address
Preferred Contact No
Email
example@example.com
Emergency Contact
Occupation
Full/Part-Time
Children Living at home

YesNo
Ages
Name of Doctor
Address
Telephone No.
Do you, or have you ever suffered from any of the following?*

Neurological Disorders (i.e. Parkinsons)Hepatitis / Liver / Digestive Problems / Kidney ProblemsEpilepseyHeart Condition / Circulation ProblemsHigh / Low Blood PressureVaricose Veins / Phlebitis/ thrombosisCancer - If yes, are you currently having chemotherapy or radiotherapyDo you have any undiagnosed lumps or swelling or areas of acute painAre you awaiting the results of any testsDo you suffer with Arthritis, Rheumatism or OsteoporosisI do not suffer with any of the above conditions
If you suffer with any of the above conditions, please provide further details
Have you had Covid-19

YesNo
If Yes, are you still experiencing symptoms

YesNo
Have you had both COVID-19 Vaccinations

YesNo
Is your menstrual cycle regular

YesNoNo longer have periods
Have you recently given birth or are breastfeeding

Recently Given BirthBreastfeeding
Are you Pregnant, Or Trying to Conceive

PregnantNot PregnantTrying to Conceive
Do you have any fertility related problems

YesNo
Have you used essential oils before

YesNo
Caution - Skin Sensitivity: Great care is taken in the choice of safe and effective essential oils for your treatment, but some oils may cause skin sensitisation or irritation in a few individuals, especially those with sensitive skin. It is impossible to avoid this slight risk completely without avoiding many otherwise safe and effective essential oils. Moreover, any symptoms that do occur will usually clear up without the need for further treatment. However, it is important that you inform me of any adverse reactions experienced so that the essential oil responsible, and any with chemically similar formulations, can be avoided in future. If you have sensitive skin, it may be necessary to carry out a 24-hour patch test before proceeding with treatment with some oils. If you do not have sensitive skin but are particularly concerned about dermal irritation or sensitisation, please let me know and I will arrange a patch test and/or only use oils that are generally known not to cause any adverse skin reactions.
Allergies or Sensitivities (i.e., food, perfume, pets, hay fever)
Please give details on any medication you are currently taking, including any homeopathic remedies
How is your diet? Please provide brief details
What to you drink in a day? Eg. Water, tea, coffee (decafinated/cafinated)
Do you have any problems with bowel or urinary health
Do you smoke?
Do you drink Alcohol? If yes, roughly how much per day / week
Do you exercise?
Do you fnd it easy to relax? How do you relax
Do you sleep well? Describe your sleep pattern.
How would you rate your energy levels 0 10 (0 being very low and 10 being very high)
How would you rate your stress levels? 0 10 (0 being very low and 10 being very high)
What are your main stressors if any?
Any other relevant information
Reason for seeking Treatment and what are you hoping to achieve from our work together?
Consent*

I confirm that the above reflects my health, as at today's date and that I will notify you of any change to my health or medical condition at my next appointment should such a change occur.
Date*

MonthDayYear
Date
I am committed to ensuring that your personal data is secure. In order to prevent unauthorised access or disclosure, I have put in place appropriate technical, physical and managerial procedures to safeguard and secure the information we collect from you.

I will contact you using the contact preferences you give me in relation to: Appointment times Information regarding the therapies I offer, or information related to your health Special offers and promotions via newsletter (you may unsubscribe from this at any time)

I will keep your information for 7 Years following your last treatment.

Your data will not be shared without your consent.
GDPR Consent*

I consent to you holding and using my information as outlined above, and understand that I may withdraw that consent at any time by emailing mail@therapeuticaromas.co.uk
Name*
Date*

MonthDayYear
Date
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