Tier 3: Full Aromatherapy Consultation Intake Form

Tier 3: Full Aromatherapy Consultation Intake Form
Let's do a deep dive into your wellness journey!
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Date
Occupation
Medical History: To provide a safe and efective aromatherapy experience, it's important that I understand your current health status. Essential oils can offer wonderful support when used appropriately, but they may also have contraindications with certain medical conditions or medications.

Additionally, many oils have multiple therapeutic properties, so the more I understand your whole health picture, the more thoughtfully I can match you with oils that provide the greatest benefit.

Please answer the following to the best of your ability. All information is kept confidential and used solely to create your personalized recommendations.
Are you currently (or possibly may be) pregnant or nursing?
Do you have any allergies or intolerance?
Do you have any medical conditions?
Are you taking any medications?
If yes to any of the above, provide more details and be sure to list any medications currently prescribed.
Which symptoms are concerning you? If using any alternative treatment, what helped? What hasn't?
In the following sections, check all that apply to you, even if minor concern.
INTEGUMENTARY SYSTEM

AcneAging SpotsAthletes FootCuts/Sores/BlistersBruisesBurnsChapped, Dry SkinEczemaFungal InfectionsInflamed SkinItching SermatitisInsect BitesOily SkinPsoriasisSunburn/WindburnScar TissueStretch MarksWartsWrinkles/Mature SkinDandruffHair Loss/ AlopeciaScalp IssuesGum IssuesToothache
MUSCULAR & SKELETAL SYSTEM

Back Aches/PainsArthritisBone SpursJoint StiffnessCarpel Tunnel SyndromeChronic PainCramps & Charley HorsesGoutHerniated DiskInflammation (injury)Muscle PainMuscle WeaknessOsteoporosisRestless Leg SyndrumRheumatismSciaticaSprains/Tendonitits
IMMUNE SYSTEM

Chronic Fatigue SyyndromeCold/FluCouphEar InfectionFibromyalgiaLyme DiseaseShinglesSore ThroatAuto Immune Disorder
CIRCULATORY SYSTEM

AnemiaAnginaArrhythmia/ AFibBlood ClotsHigh CholesterolHeart DiseaseHeart PalpitationsHigh Blood PressureLow Blood PressurePhlebitisPoor CirculationStrokeVaricose Veins
DIGESTIVE SYSTEM

Appetite, Loss ofBloatingCandidaColicConstipationCramps/ SpasmsDiabetesDiarrheaFlatulenceHeartburnHemorrhoidsHiccupsHypoglycemiaIndigestionIrritable Bowel SyndromeNausea/ VomitingMotion Sickness/TravelParasites
REPRODUCTIVE & ENDOCRINE SYSTEM

Absent MenstruationPainful MenstruationEndometriosisFertility IssuesFibroidsIrregular PeriodsLoss of LibidoMenopauseHormonal ImbalanceExcessive MenstruationPMSHypothyroidismHyperthyroidism
LYMPHATIC SYSTEM

LymphedemaInflamed Lymph NodesStagnant Lymph
URINARY SYSTEM

Bladder InfectionsEnlarged ProstateIncontinenceKidney InfectionsKidney Stones
RESPIRATORY SYSTEM

AllergiesAsthmaBronchitisChronic CoughHay FeverLaryngitisPneumoniaSinusitusSmoking Addiction
NERVOUS & LIMBIC SYSTEM

ADD/ADHDAnxietyAutismConcentration, PoorConfusionDepressionDizzinessEnergy, Lack ofExhaustion, NervousFatigue, MentalHeadacheInsomniaIrritabiltyJet LagLoss of SmellMemory ProblemsMigraineNerve DisorderNervousnessNeurological DiseaseNeuropathySeizuresShock/ Emotional TraumaStressVertigo
OTHER
CONTRAINDICATIONS: Please Check All That Apply to You.

EPILEPTICELDERLYPREGNANT/NURSINGCHILDESTROGEN-RELATED CANCER HISTORYBLEEDING DISORDERSENDROMETRIOSISPARKINSONSALLERGY TO CEDARLOW BLOOD PRESSUREBLOOD THINNER MEDICATIONSASTHMATICHIGH BLOOD PRESSUREHOMEOPATHIC REMEDIESPOOR KIDNEY FUNCTIONANTIDEPRESSANT MEDICATIONCARDIAC FIBRILLATIONRAGWEED ALLERGYSKIN SENSITIVE
Are you currently receiving other alternative treatments (Ex: Homeopathy, Acupuncture etc.)?
Have you had an Aromatherapy session before?
Do you find time to relax or meditate?
Do you find time to exercise?
Please rate your level of stress.

LowLow/MediumMediumMedium/HighHigh
How many hours of sleep do you get in an average night?
Please rate your quality of sleep. (1= worst, 5= best)

12345
Do you have oils you would like to be used or avoided in the session?
If yes, provide more details below.
Do you have any concerns you would like me to know?
If yes, provide more details below.
What would you like to get out of this aromatherapy consultation?
Which scent profile are you most drawn to? Select all that apply.

FloralHerbaceousCitrusWoodsyMintyspiceCamphoraceousMusky
Which method of application do you prefer? Select all that apply.

Direct InhalationSpray/MistDiffusionBody Oil/Lotion/ CreamMassageBath OilOther
What duration are you planning on using aromatherapy products?

Temporary (to aide in healing)Long- Term (part of a ritual)Not Sure, Please Guide Me
By signing below you acknowledge:
1. I have stated all my known conditions and have answered questions honestly.
2. I certify that I have read and fully understood and completed this form to the best of my ability,
3. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given.
4. I understand that the practitioner does not diagnose, prevent or treat illness, disease or any other physical or mental condition.
5. I understand that essential oils & aromatherapy are complementary, holistic therapy and that this protocol is not substiute for medical treatment or diagnosis.
6. I understand the following essential oil safety: I am not being advised to take essential oil products internally. I must keep all essential oil products out of the reach of children. Essential oils could be poisonous if swallowed. Essential oils must be stored in a cool, dark place. Essential oils may irritate the skin if not stored or used properly.
7. I fully undertand the above and consent to the Aromatherapy treatment to be carried out.
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You did it! You took a step forward in your wellness routine! After reviewing your intake form I will reach out to you with any questions I may have that could assist me in writing your personal recommondations. I look forward to working with you!
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