Aromatherapy Intake Form Page 3

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7. What symptoms are most difficult for you?
8. Do you have any acute conditions you would like to address?
9. Please list any allergies:
10. Are you pregnant or trying to become pregnant?
Yes
No
11. Do you have epilepsy?
Yes
No
12. Do you have high/low blood pressure?
Yes
No
13. Which oils or aromas are you drawn to?

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