Aromatherapy Client Intake Form
Name
First Name
Last Name
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment
Company Name
Civil Status
Single
Married
Divorced
Widow
Height (cm)
Weight (kg)
Select an appointment
Reason for visit
What are the oils or scents that you prefer?
What are the oils or scents that you do not prefer?
What are your expected results from this therapy?
Do you have any medication condition or illnesses that you would like us to know?
Yes
No
What is this medical condition that you want to share?
What are the symptoms that you encountered related to this condition/illness?
What are the treatments that you had tried to cure this condition/illness?
Are you currently under any physical therapy or chiropractic treatment program?
Yes
No
Do you have any physical injuries due to sports, accidents, and others?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Do you have allergies?
Yes
No
Please list your allergies and what causes it
Are you currently under any medication?
Yes
No
Please list your medications and their purpose
Do you have hypertension?
Yes
No
Do you have sensitive skin?
Yes
No
Had you experience any episode of epilepsy?
Yes
No
Did you undergo any surgical operation?
Yes
No
When did you had the procedure and what is the reason?
Please fill out the table and select if you have the following condition
Rows
Yes
No
Remarks/Notes
Asthma
Sinus congestion
Glaucoma
Cancer
Dizziness
Headahces
Nervousness
Numbness
Arthritis
Backache
Constipation
Menopausal
Hot flashes
Breast Lumps
Excessive urination
Cardiovascular disease
Previous stroke
Varicose veins
Chest pain
Difficulty of breathing
Agreement & Consent
Patient Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: