Online Bespoke Clinical Aromatherapy
Consultation Form
Name
Full Name
Date of Birth
Address
Street Address
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City
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Postal Code
Phone Number
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Country Code
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Area Code
Phone Number
Email
example@example.com
Kindly read the below list of health conditions carefully and tick anything that is relative to you now or has been in the past. Knowing this information will enhance your bespoke clinical service.
Heart Conditions
High/Low Blood Pressure
Diabetes
Epilepsy
Auto Immune Conditions
Food/Nut Allergies
Cancer/Chemotherapy
Stroke
Hepatitis
Kidney/Liver Problems
Pregnancy/Breastfeeding
IVF
Skin Conditions (psoriasis/eczema/acne/dermatitis)
Headache/Migraine
Recent Operations (within the last 12 months)
Depression/Anxiety
Other
None of the above
Are you currently taking any medications? If yes please list them below:
Please list names and amount you take
Tell me about your stress levels at this moment in time:
High Stress Levels/Feeling Overwhelmed
High but I am ok with it
Manageable
Lower than usual
I do not feel stress is my main concern
None of the above
Tell me about your energy levels
Low energy levels with no motivation
Varied energy levels, I can feel groggy
I feel my energy is all over the place
High energy good motivation
I feel hyper active and a bit out of control at times
None of the above
What are your main concerns today? Please give an explanation of what you would like to treat with your products and what kind of results you may be looking to achieve.
Do you have or have you ever had any reactions to cosmetic, skincare or medicinal products. If yes please detail:
Tell me about your sleep patterns:
7-8 hours each night and it is enough for me
4-6 hours each night and it is enough for me
10-12 hours I love to sleep
I am sleeping less than normal at the moment
I feel like I am sleeping more than normal at the moment
None of the above
Tell me about any past experience of Aromatherapy treatments or products you have used. How did it work for you?
Do you have any digestive troubles such as:
Constipation
Irritable Bowel Syndrome
Irregular bowel movements/Diarrhea
Flatulence
Acid Reflux
Anxiety related digestive troubles
Nausea
None of the above
What type of product/s do you feel would best suit your needs. We will also discuss the options during your consultation:
Bespoke Aromatherapy Inhaler
Bespoke Aromatherapy Roller Ball Blend
Bespoke Aromatherapy Therapeutic Balm
Bespoke Aromatherapy Body Oil
Bespoke Aromatherapy Skincare
Other
Tell me about your skin:
Normal to Dehydrated
Sensitive/Redness
Oily/Unbalanced
Very dry
Hormonally Reactive
Affected by the weather and change in climates
Stress related break outs
Dull and lacking radiance
Skin Condition (psoriasis, eczema, dermatitis, impetigo, fungal infections)
None of the above
DisclaimerPrivacy Policy - Protecting your personal dataAll information provided on this form is totally confidential. No information provided or anything discussed will be shared with any other person or parties. This form will be kept in a secure place for only as long as is deemed necessary I agree that I have completed this form to the best of my ability and knowledge, and understand my responsibility to inform my therapist if any of the above information changes at any time.
Please sign clearly below - without a signature treatment will not proceed.
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