"Aromatherapy Intake Form - Sunshine Healthcare Center"

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Angie Trussell, RN, NREMTP, RMT
13660 N 94th Drive Ste. C-4
Peoria, AZ 85381-4841
ph (623) 266-1722 | fax (623) 266-1746
Aromatherapy Intake Form
Each blend is created on an individual basis, based on the information provided in this form. Please answer each
question to the best of your ability in an effort to find the product that works best for you.
Name: ______________________________________________________________________________________
Address: ____________________________________________________________________________________
Primary phone #_______________________________
OK to leave a message? YES NO
Email: ______________________________________________________________________________________
Preferred method of communication:
Email
Mail
Text
Voice message
Do you have sensitive skin? YES NO Please describe if yes: _________________________________________
Are you currently on blood thinners? YES NO
Are you pregnant?
YES NO
Do you use any medications on you skin: YES NO
PATCHES
CREAMS ____________________________
____________________________________________________________________________________________
Do you have High Blood Pressure, Seizures, Diabetes, bleeding/clotting disorders or any other health condition that
you are taking medication for? ___________________________________________________________________
____________________________________________________________________________________________
Do you have any allergies? ______________________________________________________________________
____________________________________________________________________________________________
Are their any smell you dislike? ___________________________________________________________________
What are some of your favorite smells? ____________________________________________________________
From the following list please circle the products you would use. Please cross off any you would not use.
Room spray
Hand sanitizer
Roll on oil
Bath salts
Hand lotion
Perfume spray
Massage oil
Salt inhalant
Angie Trussell, RN, NREMTP, RMT
13660 N 94th Drive Ste. C-4
Peoria, AZ 85381-4841
ph (623) 266-1722 | fax (623) 266-1746
Aromatherapy Intake Form
Each blend is created on an individual basis, based on the information provided in this form. Please answer each
question to the best of your ability in an effort to find the product that works best for you.
Name: ______________________________________________________________________________________
Address: ____________________________________________________________________________________
Primary phone #_______________________________
OK to leave a message? YES NO
Email: ______________________________________________________________________________________
Preferred method of communication:
Email
Mail
Text
Voice message
Do you have sensitive skin? YES NO Please describe if yes: _________________________________________
Are you currently on blood thinners? YES NO
Are you pregnant?
YES NO
Do you use any medications on you skin: YES NO
PATCHES
CREAMS ____________________________
____________________________________________________________________________________________
Do you have High Blood Pressure, Seizures, Diabetes, bleeding/clotting disorders or any other health condition that
you are taking medication for? ___________________________________________________________________
____________________________________________________________________________________________
Do you have any allergies? ______________________________________________________________________
____________________________________________________________________________________________
Are their any smell you dislike? ___________________________________________________________________
What are some of your favorite smells? ____________________________________________________________
From the following list please circle the products you would use. Please cross off any you would not use.
Room spray
Hand sanitizer
Roll on oil
Bath salts
Hand lotion
Perfume spray
Massage oil
Salt inhalant
I have answered these questions truthfully and to the best of my ability. I will use these products as directed and
notify my practitioner with any questions or concerns. For any allergic reaction I will stop using and seek immediate
medical attention. I will avoid UV/sun exposing to any area of skin that the oils have been applied to for 24 hours. I
understand aromatherapy is not intended as a cure, but to help aid in symptom management. If any skin irritation is
present applying a base oil to diffuse the essentials can be helpful, such as olive or coconut oil. I will notify my
practitioner and/or stop use if any changes to my health occur or any chance of pregnancy.
Signature:________________________________________________ Date : _____________________________
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