Aromatherapy Intake Form

Name:

Date:

Address:

State:

Zip:

Phone:

Email:

DOB:

Age:

Occupation:

What is your primary concern?

Month/Year of onset of concern:

Your idea of the cause:

What makes it feel better?

What makes it feel worse?

Are you pregnant?

Are you trying to become pregnant?

Are you breastfeeding?

Chronic Conditions (please check)

___ High Blood Pressure

___ Low Blood Pressure

___ Epilepsy

___ Any seizure disorder other than epilepsy:

___ Allergies, please list:

Are you under the care of a physician? If so, please list the condition(s) you are being treated for:

Medications: Please list all medications, herbs and supplements you are taking:

Surgeries: Please list type and date of all surgeries:

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Parent category: Business