Essential Oil Wellness Support
Like the fruits, flowers, plants and trees they come from, each essential oil is a healing elixir that holds a particular frequency of wellness for you. Francesca’s alchemical expertise can discern what custom combination aligns most beautifully with your physical, emotional and spiritual needs. Complete this information to receive Francesca’s suggestions for what best resonates with your highest health and wellness. The essential oils can be purchased online at www.francescabonta.com and delivered straight to your home. Free pick-up is also an option in Cobourg or Liberty Village, Toronto.
Name
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Last Name
Birth Date
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Month
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Year
Date
Gender
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Email
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Occupation
How did you hear about me?
IG, email, friend, google, current client, etc
In summary what are your main concerns so I can best support you?
Prescription Medication
Over the counter medication/supplements (vitamins, minerals, herbs, etc)
Is there anything else I should know before we continue?
Have you experienced any of the following?
Physical Injuries
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No
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Traumas
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Stress Level
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Usual
Heavy
Unmanagable
other
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Do you have a family history of any serious illnesses?
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What is currently happening for you in these areas?
Exercise
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No
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Sleep Well
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No
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Smoke
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Yes
No
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Alcohol / Substance use
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Healthy Eating
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Food Allergies / Intolerances
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No
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Gut Health
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Please select all that apply
Headaches
Neck pain
Back pain
Pop, click or jaw pain
Pins and needles
Dizziness
Loss of balance
Fatigue
Memory loss
Loss of smell
Difficulty swallowing
Bad breath
Nausea
Indigestion
Diarrhoea
Constipation
Food sensitivities
Epilepsy
Hearing problems
Loss of taste
Please select all that apply
High blood pressure
Low blood pressure
Chest pain
Shortness of breath
Muscle cramps
Fluid retention
Fainting
Eyes light sensitive
Eczema
Cancer
Kidney/Bladder trouble
Asthma
Regular colds/flu
Restless legs
Diabetes
Migraine
Vision problems
Allergies
Stroke
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Signature
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PARENT/GUARDIAN TO COMPLETE IF PATIENT IS LESS THAN 18 YEARS OF AGE
I
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Parent/Guardian of
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consent to essential oil support from Francesca Bonta, Holisitc, .
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