Aromatherapy Intake Form printable pdf download

Angie Trussell, RN, NREMTP, RMT

13660 N 94th Drive Ste. C-4

Peoria, AZ 85381-4841

ph (623) 266-1722 | fax (623) 266-1746

Aromatherapy Intake Form

Each blend is created on an individual basis, based on the information provided in this form. Please answer each

question to the best of your ability in an effort to find the product that works best for you.

Name: ______________________________________________________________________________________

Address: ____________________________________________________________________________________

Primary phone #_______________________________

OK to leave a message? YES NO

Email: ______________________________________________________________________________________

Preferred method of communication:

Mail

Text

Voice message

Do you have sensitive skin? YES NO Please describe if yes: _________________________________________

Are you currently on blood thinners? YES NO

Are you pregnant?

YES NO

Do you use any medications on you skin: YES NO

PATCHES

CREAMS ____________________________

____________________________________________________________________________________________

Do you have High Blood Pressure, Seizures, Diabetes, bleeding/clotting disorders or any other health condition that

you are taking medication for? ___________________________________________________________________

____________________________________________________________________________________________

Do you have any allergies? ______________________________________________________________________

____________________________________________________________________________________________

Are their any smell you dislike? ___________________________________________________________________

What are some of your favorite smells? ____________________________________________________________

From the following list please circle the products you would use. Please cross off any you would not use.

Room spray

Hand sanitizer

Roll on oil

Bath salts

Hand lotion

Perfume spray

Massage oil

Salt inhalant

Aromatherapy Intake Form