Etheral Health - Aromatherapy Well-Being Consultation Form

Aromatherapy Well-Being Consultation Form

Charlotte Coleman MFHT
Name
Age
Email
Contact No (optional for updates)
Are you currently pregnant or breastfeeding?
If you answered 'Yes' please include baby's due date or how old baby is. This is to ensure only oils safe for you and your baby are prescribed.
Have you used an aromatherapy service before?
Any specific reason/focus for treatment:
How would you rate your energy levels?
How would you rate your stress levels?
How would you describe your sleep pattern?
What do you do for relaxation?
Are there any scents you particularly love or dislike?
Do you suffer or have you suffered from any of the following? Tick any that apply

Other
Please give details of any conditions ticked:
Do you have any allergies or intolerances? Please give details:
Are you taking any medication? Please give details:
To narrow down the support needed (Please give as much information as you're able to)
What physical concerns do you have at present?
If you're looking for help with skincare, can you tell me a bit about your skin type and any specific concerns? What does your current skincare regime include?
If you are looking for emotional support, what emotions are most present in your life currently? Are these general emotional moods, or do you feel they are emotional responses that increase in certain situations? How do you feel about your state of mind at present?
What is the most pressing change you would like to see as a result of our consultation?
Do you have any preferences for your support blend product type?
Product options: Inhalers, Bath products, Body oils, Pure essential oil blends for multi use.
Please read carefully and sign below

"I the undersigned have completed the form as fully and accurately as I can. I believe the details to be correct and I consent to receiving treatment from Charlotte Coleman - Aromatherapist and acknowledge she will be storing this record card. I release the practitioner from any negligent mispresentation that may be contained in this form"
Print
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: