Aromatherapy Intake Form

                                                                Aroma Clinic Intake Form
Client Name: Today's Date: 
Address Age:
Phone: Date of Birth:
Email: Gender:    M          F
Reason for Visit Chronic Conditions:
What is your primary concern? High Blood Pressure      Y          N
  Low Blood Pressure       Y          N
  Epilepsy                                 Y           N
Month/Year of onset of concern: Any Seizure disorders:             Y         N
Your idea of the cause: Allergies, Please list:               Y          N
  Are you pregnant?     Y         N 
What makes it feel better? Are you trying to become pregnant?       Y          N
  Are you breastfeeding?    Y          N
  Social History:
What makes it feel worse? How much per day do you use of the following?
  Coffee, tea, soft drinks
Physician Care Cigarettes, cigars, tobacco
Are you under the care of a physician?      Y         N Alcohol
If so, what condition are you being treated: Drugs
  Please discribe your exercise regimen:
Medications: Please list all medications, herbs and supplements  Activities:
you are taking: How many hours of exercise a week?
  How many hours of sleep do you get per night during the week?
  Please provide any other information that you think we should know to treat you safely?
Surgeries:  Please list type and date of all surgeries:
Aroma Questions:
Are there particular scents or aromas that disturb you?  
Are ther particular scents or aromas you enjoy?  
Do you have allergic reactions to any scents or aromas? If so, list.  
Other Concerns:

Are there other symptoms or concerns that have not been covered?



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