Bespoke Product Questionnaire

Bespoke Product Questionnaire

Please contact me if you have any questions while filling in this form on 07495-462278.
Who is this bespoke aromatherapy product for?

First NameLast Name
What type of product(s) are you after?
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Date of birth

DayMonthYear
Date
What kind of support do you want this bespoke product to provide? In your own words, please explain both the emotional and/or physical aspects.
How would you describe your current stress levels and emotional health?
Are there any scents you particularly love or really dislike?
Are you currently pregnant, trying to conceive, recently given birth or breastfeeding? Please include due date and/or age of baby if applicable so I can ensure safety of oils used.
Are you currently on any medication? If so, please list...
Please list any past or present health conditions...
Please list any skin conditions that I should know about...
Have you had any operations or major accidents in the past 5 years?
AsthmaCancerDiabetesEpilepsyHeadaches / MigrainesHeart conditionLow or High blood pressureSkin conditionSwelling/oedema/lipodema
If you answered 'yes' to any of the above, please give details...
Do you have any allergies or intolerances?
Is there any other information you feel I should know?
Disclaimer: I confirm that the information I have given is correct. I also agree to make the therapist aware of any changes to my health and circumstances whilst using my bespoke aromatherapy product. I will not let anyone else use my products. Please sign below and date to confirm.
Signature

Powered by Jotform SignClear
Date

DayMonthYear
Date
Should be Empty: