"Aromatherapy Intake Form"

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Aromatherapy Intake Form
Patient Information
Patient Name:
DOB:
Sex:
Home Phone:
Cell:
Address:
Medical History
Current Chronic Conditions:
Current Acute Conditions:
Most Problematic Symptoms:
Treatments:
Effective?
Current Medications:
Recent Surgeries:
Allergies:
Are you pregnant?
Yes
No
Trying?
Yes
No
Breastfeeding?
Yes
No
Do you have epilepsy?
High/low blood pressure?
Hours sleep per night:
Exercise Activities:
Hours per week:
Aromatherapy
Reason for Visit:
Most Pleasing Scents/Oils:
Least Pleasing Scents/Oils:
Allergies/Irritations to any Scents/Oils:
Other Information:
Concerns:
I understand that Essential Oils are for external use only, and must be kept in a cool, dark place. I will stop using Essential
Oils if they cause skin irritation or other unpleasant reactions. I understand that Essential Oils are not for use on infants
under the age of one year, and should be used with caution on children under the age of five years.
I hold my aromatherapist harmless for any and all injuries, reactions, or illnesses resulting from these aromatherapy
sessions or provided products.
Patient
Date
www.FreePrintableMedicalForms.com
Aromatherapy Intake Form
Patient Information
Patient Name:
DOB:
Sex:
Home Phone:
Cell:
Address:
Medical History
Current Chronic Conditions:
Current Acute Conditions:
Most Problematic Symptoms:
Treatments:
Effective?
Current Medications:
Recent Surgeries:
Allergies:
Are you pregnant?
Yes
No
Trying?
Yes
No
Breastfeeding?
Yes
No
Do you have epilepsy?
High/low blood pressure?
Hours sleep per night:
Exercise Activities:
Hours per week:
Aromatherapy
Reason for Visit:
Most Pleasing Scents/Oils:
Least Pleasing Scents/Oils:
Allergies/Irritations to any Scents/Oils:
Other Information:
Concerns:
I understand that Essential Oils are for external use only, and must be kept in a cool, dark place. I will stop using Essential
Oils if they cause skin irritation or other unpleasant reactions. I understand that Essential Oils are not for use on infants
under the age of one year, and should be used with caution on children under the age of five years.
I hold my aromatherapist harmless for any and all injuries, reactions, or illnesses resulting from these aromatherapy
sessions or provided products.
Patient
Date
www.FreePrintableMedicalForms.com