Sunroot Aromatics Client Intake Form: Incense

Sunroot Aromatics

Incense Blend Client Intake Form
Dear Client and Friend,

Above all else, this is a Safe Space. Please know that the information provided is highly confidential and will not be shared. Feel free to include any hardships, deep thoughts, desires, fears, dreams or personal matters that are present. This special information allows me to conjure a blend that is sacred: resonating just for you. My only intention as a Certified Aromatherapist/Traditional Incense Crafter is to provide enchantingly joyful aromatic remedies that carry deep personal meaning; connecting us with our heart. I look forward to working with you!

Sincerely, Jenifer Wolfe
Name

First NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for visit
What are the aromas that you prefer?
What are the aromas that you do not prefer?
Do you feel drawn to a certain plant, tree, flower or herb?
Do you feel drawn to a certain crystal or gemstone?
What are your expected results from this special incense therapy?
Do you have any medical condition or illnesses that you would like us to know?

YesNo
What is this medical condition or illness that you want to share?
What are the symptoms that you encountered related to this condition or illness?
What are the treatments that you had tried to cure this condition/illness?
Are you pregnant or breastfeeding?

YesNo
Do you wish to become pregnant?

YesNoUndecided
Do you have allergies?

YesNo
Please list your allergies and what causes it
Are you currently under any medication?

YesNo
Please list your medications and their purpose
Do you have hypertension?

YesNo
Do you have sensitive skin?

YesNo
Had you experience any episode of epilepsy?

YesNo

Please fill out the table and select if you have the following condition

	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

Feel free to leave any questions, comments or concerns
Agreement & Consent
Patient Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Sunroot Aromatics

Agreement & Consent