Client Intake Form (Page 3 of 4) in pdf

Medication/Dosage/Frequency _________________________________________ Reason ____________________

Do you have any allergies? If so, please indicate ______________________________________________________

Check any that you experience more than once per week:

⃝ Headache

⃝ Fatigue

⃝ Faintness/Dizziness

⃝ Constipation

⃝ Loose Bowels

⃝ Excessive Urination

⃝ Respiratory Problems

⃝ Indigestion

⃝ Cold Hands/Feet

⃝ Stomach Upsets

⃝ Nervousness

⃝ Muscle Soreness

⃝ Anxiety

⃝ Chest Pains

⃝ Heart Issues

⃝ Poor Appetite

⃝ Epilepsy

⃝ Hepatitis

⃝ Diabetes

⃝ Blood Clots

⃝ Tightness in the body, where? _________________ ⃝ Weakness in body, where? ______________________

⃝ Immune Issues? Type? _______________________ ⃝ Skin issues? Type? _____________________________

Do you experience pain? ⃝ Seldom ⃝ Frequently ⃝ Always Where? ________________________________

Do you exercise? Y

N Type ______________________________ Frequency ____________________________

Other or comments on above: ____________________________________________________________________

_____________________________________________________________________________________________

For Women Only:

Are you trying to conceive? Y N Are you currently pregnant? Y N If yes, how far along are you? __________

What kind of birth control do you use? _________________________ Started menopause? Y N Finished? Y N

Do you suffer from PMS? Y N Please list any PMS symptoms? _________________________________________

For Men Only:

Do you suffer from prostate/erectile dysfunction? Complaints? _________________________________________

_____________________________________________________________________________________________

Family History of Illness? Family member afflicted? ___________________________________________________

_____________________________________________________________________________________________

Is there anything else I should be aware of that I have not already asked? _________________________________

_____________________________________________________________________________________________

Are there any scents you do not enjoy?

(e.g. floral, citrus, camphor, etc.) _________________________________________________

Enhancements Aromatherapy LLC

Client Intake Form

Client Intake Form Page 3

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