"Aromatherapy Intake Form"

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Aromatherapy Intake Form
Name:_________________________________________
Date of Birth:__________________
Emergency Contact:________________________________ Phone #_________________
Please read all of the information thoroughly
Please read all of the information thoroughly
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
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,
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
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,
your medications and/or medical conditions,
do do
not interact with the essenti
not interact with the essenti
al oil of your choice
al oil of your choice
We can
We can
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
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.
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
Choose one of the
of the
of the following
of the
following
following
following
essential oils to compliment your session today
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
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
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
Eucalyptus
Asthma
Sinus Pain & Inflammation
Respiratory Infections & Cough
Exhaustion & Mental Sluggishness
Increase Blood Flow to the Brain
Pain Relief
Aromatherapy Intake Form
Name:_________________________________________
Date of Birth:__________________
Emergency Contact:________________________________ Phone #_________________
Please read all of the information thoroughly
Please read all of the information thoroughly
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
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,
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
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,
your medications and/or medical conditions,
do do
not interact with the essenti
not interact with the essenti
al oil of your choice
al oil of your choice
We can
We can
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
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.
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
Choose one of the
of the
of the following
of the
following
following
following
essential oils to compliment your session today
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
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
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
Eucalyptus
Asthma
Sinus Pain & Inflammation
Respiratory Infections & Cough
Exhaustion & Mental Sluggishness
Increase Blood Flow to the Brain
Pain Relief
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
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
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_____________________
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