Client Intake Form
Reason for visit:
What is your primary health concern?____________________________________
When was the year/month of the onset of concern?_________________________
What have you tried that makes it better?________________________________
What makes it feel worse?_____________________________________________
Chronic conditions (Please check those that apply)
High Blood Pressure______ Low Blood Pressure______
Epilepsy_______ Any seizure disorder_____ Allergies____
Are you pregnant?___________Are you trying to become pregnant?____________
Are you under the care of any health practitioner? If so list the conditions you are being treated for. ___________________________________________________
Please list all medications, herbs and supplements you are presently taking?____________________________________
Please list all surgeries and the dates._____________________________________
Do you exercise regularly?__________________Times per week?____________
Have you ever experienced any allergic reactions to any substances? (food, environment)_____________________________________
Do you currently smoke?______________
How long have you smoked?_________________
Do you drink any caffeinated drinks?_________
Please rate your level of stress. 1-10 with 10 being highest)_________________
How many hours of sleep do you get a night?___________
Please provide any other information you think we should know in order to treat you safely and effectively?____________________________________________________
______Menopausal______Hot Flashes______Mood swings______Irregular cycle
______Breast Lumps______Infertility______Vaginal Discharge______Lower Back
______Mood swings______Veneral Disease
Muscles & Joints
_____TMJ/Popping Jaw_____Mobility Limitations_____spinal Curvature
_____Sprained tendons/muscles _____Swollen Joints_____Stiff Neck
_____Heart Attack_____Heart Disease_____High blood Pressure_____Low blood
Pressure_____Pain In Heart_____Poor Circulation_____Swelling in Ankles
_____Swelling in Joints_____Previous Stroke_____Heart Murmur
_____Boils_____Acne_____Dehydrated (Lack of Water)_____Dryness (Lack of oil)
_____Excessive Urination_____Water Retention
Eyes, Ears, Nose & Throat
_____Asthma_____Ear Aches_____Eye Pains Wet/Dry_____Failing Vision
_____Glaucoma_____Sinus Infection_____Sore Throat_____Sinus Congestion_____
Asthma_____Chest Pain_____Difficulty Breathing_____Dry cough_____Spitting blood
Where do you want to be and what do you need to get there?
Note: Must be signed by every client.
Please read and sign.
Aromatherapy is an incredible healing art and science that supports and enhances the individual’s ability to heal and maintain health.
I have stated all my known conditions and have answered all questions honestly.
I understand that this consultation is designed to gather information so that my practitioner is able to design and create aromatic products based upon my unique needs and goals. I understand if my condition changes I take upon myself to keep the practitioner informed.
I understand the consultant does not diagnose, prevent or treat illness, disease, or any other physical or mental conditions.
I understand the treatment is not a substitute for medical treatments and/or diagnosis, and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.
This consultation does not take the place of a medical evaluation.
I hold my essential oil consultant (Name of consultant) ______________________
harmless for any injuries or negative effects I may experience as a result of using the products I receive from this consultant.
I hold Applied Aromatic Institute harmless for any injuries or negative effects I may experience as a result of using the products I receive from the consultant.
Print client name:_________________________________
Print student name_________________________________