Aromatherapy Intake Form (Page 2 of 2) in pdf

Speeding up the healing of wounds and insect bites

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

other seizure disorder, diabetes or high blood pressure.

4. 4. 4. 4. Orange

Orange

Orange has a sweet, fruity scent reminiscent of the fruit. It’s sure to energize and lift your mood

almost immediately! It is beneficial for:

Relieve Anxiety, Anger & Depression

Detoxify the Body (Stimulates Lymphatic System) & Boost Immunity

Improve Digestion & Relieve Constipation

Nourish Dry, Irritated & Acne Prone Skin

Promotes Feelings of Happiness & Warmth

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

other seizure disorder, or plan to be in the sun for the next 12 hours.

5. 5. 5. 5. Spearmint

Spearmint

Spearmint has a sweet, minty aroma that is quite refreshing. It is a gentler mint than most, but

has many of the same benefits. It is beneficial for:

Digestive Conditions, Menstrual Cramps & Nausea

Headaches & Migraines

Fatigue

Relieve Muscle Pain

Respiratory Problems

Stimulate Nerves, Brain Function and Blood Circulation

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

kidney conditions.

**Additional information that I feel my therapist should be aware of:

______________________________________________________________________________

I understand that essential oils will only be used topically and in proper diluted form. I have

thoroughly read and acknowledge that I do not have any conditions contraindicated for the use of

essential oils. I am not taking any medication nor do I have any medical conditions that may cause

an interaction with essential oils. I acknowledge that I have the option to do a patch test today on

my forearm prior to my treatment. I affirm that I have stated all my known medical conditions

honestly. I agree to keep the therapist updated as to any changes in my medical profile and

understand that there shall be no liability on the therapist’s part should I fail to do so.

Client Signature______________________________________ Date_____________________

Aromatherapy Intake Form Page 2