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Aromatherapy consultation form Date:
Essential
oils are totally safe when administered by a qualified Aromatherapists.
However, there are certain conditions that the Aromtherapist needs to
know about before treatment can take place.
If it is considered to be in your best interest, the Aromatherapist may
require you to consult your Doctor before treatment can be given.
Name:
Date of birth:
Occupation:
Address:
Telephone:
Daytime:
Evening:
Name
of Doctor:
Address:
MEDICAL DETAILS
Do
you have, or have you ever had the following:
(Please give details where applicable)
Circulatory
disorder
Heart condition
High or low
blood pressure
Thrombosis
Varicose
vein(s)
Epilepsy
Abdominal
complaint. Please specify:
Skin disorder.
Please specify:
Diabetes
Dysfunction of
the nervous system
Recent
hemorrhage or swelling
Recent
operation / fracture / sprain
Nut allergy
Wheat allergy
or intolerance
A potentially
fatal or terminal condition (e.g. cancer)
Are you
currently under GP or hospital care? Details:
Are you taking
any medication including herbal remedies?
Please specify:
FEMALE CLIENTS
Is it possible
that you may be pregnant?
Do
you suffer from the following?
Menstruation
problems eg: PMS, pain,
Perimenopausal/Menopausal problems
GENERAL HEATH (please circle)
Is your
general health
GOOD AVERAGE
POOR
Are your
energy levels
HIGH AVERAGE
POOR
Is your
stress level
HIGH AVERAGE
LOW
Do you
sleep
WELL AVERAGE
POOR
Weight:
UNDERWEIGHT AVERAGE
OVERWEIGHT OBESE
Type
of exercise undertaken (and how frequent):
Typical
weekly alcohol consumption:
Do
you smoke? If so, how many a day:
Number
of cups of tea/coffee a day:
Do
you have any hobbies? Please give details:
How
do you relax?
HEALTH RELATED PROBLEMS
Do you
have or have recently suffered from any of the following
(please circle):
Skin
complaints:
Allergies
Dermatitis Eczema
Psoriasis
Other
(please specify):
Circulation/joints
Arthritis
Aches and pains
Sciatica
Chilblains
Oedema
Rheumatism
Other:
Respiration
Asthma
Breathing difficulties
Bronchitis
Throat infection
Sinusitis
Colds 'Flu
Other
(please specify):
Digestion:
Constipation
Indigestion
Colitis Candida
Other:
Urinary
problems
Cystitis
Thrush
Fluid retention
Other
(please specify):
Stress/Anxiety
Depression
Headaches Migraine
Insomnia
Tension
Other
(please specify):
Are their any other details not mentioned above
which you would like help with as part of your treatment?:
Are you currently undergoing any other
Complementary treatment? Please give details:
Summary
of any problems you would like treatment to address:
(THERAPIST
USE ONLY: Is GP referral required?
YES NO)
CLIENT
DECLARATION
I
declare that the information I have given is correct and promise to notify the
Therapist should there be any changes to my health.
As far as I am aware I can undertake treatment without any adverse
affects. I have been fully informed
about any contraindications and am willing to proceed with the treatment.
Client's
signature ……………………………………………
Therapist's signature ………………………………………. Date: