Fillable Aromatherapy Intake Form printable pdf download

Aromatherapy Intake Form

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ACP-1 ACTIVITY:

AROMATHERAPY CLIENT INTAKE FORM

In this course, we covered making aromatic and therapeutic blends for treating sicknesses and

diseases. You will find most people are interested in finding answers to their health concerns

and are seeking an alternative to prescribed medicines. As you have learned, therapeutic grade

essential oils do offer us a great option to meds!

For those who would like to pursue a career in aromatherapy as a Certified Aromatherapist, performing a

case study will give you an opportunity to start your practice. In this activity, you will use this intake form

just like you would if you were practicing clinical aromatherapy.

Use this form to collect data for your client (this can be yourself or a friend). It is important to get as much

health history as possible in guiding users on which essential oils will benefit them. With this information,

write up a case study (using the 2nd form that follows) for a prescribed treatment plan using essential oils.

Feel free to ad lib if you do not have a “health issue” or a friend willing to volunteer.

Aromatherapy Intake Form

First Name:

Last Name:

Date of Birth:

Address:

City:

State:

Zip:

Phone Number:

Email:

1. How would you describe your overall health?

Aromatherapy Intake Form

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