Aromatherapy Intake Form Page 2

Aromatherapy Intake Form

Social History

1. How much per day do you use of the following?

a) Coffee, tea, soft drinks

b) Alcohol

c) Cigarettes, cigars, tobacco

d) Other drugs

2. Please describe your current exercise regimen:

Hours per week:

Activities:

[ ] No Exercise

3. How many hours of sleep do you usually get per night during the week?

4. Please provide any other information that you think we should know in order to treat you safely and effectively:

Aroma Questions

Are there particular scents or aromas that disturb you?

Are there particular scents or aromas that you especially enjoy?

Do you have allergic reactions to any scents / Flowers / Trees? If so, which ones:

Dietary Questions

Are you allergic to any foods?

What is a typical dietary day for you (what do you eat for breakfast, lunch and dinner)? Please include drinks, snacks, and desserts.

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Parent category: Business