Aromatherapy Intake Form printable pdf download

Aromatherapy Intake Form

Name:_________________________________________

Date of Birth:__________________

Emergency Contact:________________________________ Phone #_________________

Please read all of the information thoroughly

Please read all of the information thoroughly as there are some conditions in which essential oils

as there are some conditions in which essential oils

should not be used,

should not be used, due to contraindications

due to contraindications or possible side effects

or possible side effects. . . . * * * * Please verify that any of

Please verify that any of

should not be used,

due to contraindications

or possible side effects

Please verify that any of

your medications and/or medical conditions,

your medications and/or medical conditions, do

do not interact with the essenti

not interact with the essential oil of your choice

al oil of your choice. . . .

your medications and/or medical conditions,

do do

not interact with the essenti

al oil of your choice

We can

We can perform a patch test on your forearm before your session begins to check for any irritation

perform a patch test on your forearm before your session begins to check for any irritation

or reaction. If you would like a patch test, please ask your therapist.

or reaction. If you would like a patch test, please ask your therapist. Choose one

Choose one

Choose one of the

of the

of the following

of the

following

essential oils to compliment your session today

essential oils to compliment your session today: : : :

essential oils to compliment your session today

1. 1. 1. 1. Lemongrass

Lemongrass

Lemongrass has a refreshing, citrusy aroma with a hint of earthy undertones. It is beneficial for:

Boost confidence

Depression

Fever, Cold & Cough

Exhaustion

Stomach ache & Intestinal Spasms

Achy Muscles and Joints

Relieve Stress, Anxiety, Depression & Irritability

Lower Blood Pressure

*Do not use if you are a child, pregnant, breastfeeding or trying to get pregnant, have diabetes,

hypoglycemia, liver disease, kidney disease, or plan to be in the sun for the next 12 hours.

2 2 2 2 . . . . Lavender

Lavender has a calming, floral scent. It is the most popular essential oil used today and has a

Lavender

host of benefits! It is beneficial for:

Relieve Stress

Insomnia & Restlessness

Asthma & Respiratory problems

Depression & Anxiety

Relieve Muscle & Joint Pain

Stomach Problems, Menstrual Cramps, & Hormonal Imbalance

Psoriasis & Eczema

Burns, Acne, Wounds & Itchy Skin

Lower Blood Pressure

*Do not use if you are a child, pregnant, breastfeeding or trying to get pregnant.

3. 3. 3. 3. Eucalyptus

Eucalyptus has a strong, clean aroma that will definitely open up your airways. It is beneficial for:

Eucalyptus

Asthma

Sinus Pain & Inflammation

Respiratory Infections & Cough

Exhaustion & Mental Sluggishness

Increase Blood Flow to the Brain

Pain Relief

Aromatherapy Intake Form

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