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New Aroma Acu-therapy Client Intake
Please take a few minutes to complete this intake form. This will assist in assessing your needs. 
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Important Directions Please Read
Important Directions! Please Read
-You CAN skip questions that are unrelated to you.
Most people are able to discern what problems they have and are able to report them. Often times people will think, "Why should I mention the ringing in my ears when I really am worried about my back pain?" In Chinese medicine, the ringing in the ears helps to determine where the back pain is, or is not, originating from. Your results will be better with accurate information inputs.
Disclaimer Please
Disclaimer
The results of this questionnaire do not constitute a diagnosis. The questionnaire is designed for you to better understand "patterns" of imbalance that you have according to Traditional Chinese Medicine. For a true diagnosis and prescription you will need to consult directly with Michelle Lally. www.AromaTherapyLKN.com

This form does not address acute health conditions such as a viral or bacterial infection. Not intended for children or nursing or pregnant women.
Thank you!
Strategy
Chinese medical diagnostic-treatment strategy overview
Lifestyle and dietary recommendations
Acupressure prescription (Acu-sticks not included in cost)
Appropriate topical herbal recommendations (not included in cost)
Michelle Lally will review your personal health information and email a synopsis to you; allow several business days after completing the Google form for her to complete this. This evaluation is more detailed than the free evaluation and asks specific questions about your health concerns which are fully addressed. We do not offer a  Refund. This will all depend on our self care routine and offer a great tool for you to use at home with a self care routine created specifically for you.
Email *
Address, City, State, Zip
Phone Number *
Occupation *
Age *
Main Health Issue *
Past Surgeries, Hospitalizations
Allergies
Health Issues
Yes
No
High Blood Pressure
Diabetes
Kidney issues
Reproductive Issues
Blood disorder
Sinus issues
Migraines
Respiratory issues
Cancer
Circulatory & Cardiovascular Issues
Auto-Immune
Digestive Issues
Mental Health, Behavioral Issues
Clear selection
Women:
Yes
No
Are you pregnant
Are you using birth control
Menopause
Are your cycles regular
Clear selection
Are you allergic or sensitive to any essential oils, herbs, supplements, food, list all.
Other Health Issues
Medications You Are Taking
Where is your pain, check all that apply
Column 1
Head
Neck
Shoulder
Upper back
Middle back
Low back
Hip
Leg
Knee
Ankle
Foot
Arm
Elbow
Wrist
Hand
Sciatica
Plantar Faciatis
Ringing in Ears
Do you wake up in the middle of the night? Time?
Pain worse on Left or Right Side *
Required
What time is the pain worse?
What therapies have you tried, list whether they have helped you.
Do you smoke?
Do you drink
Clear selection
Recreational drugs
Clear selection
What is your stress level
Clear selection
How is the quality of your sleep
Clear selection
Sleep Issues
Yes
No
Trouble falling asleep
Trouble staying asleep
Waking at night to go to the bathroom
Nightmares
Unable to wake up
Clear selection
Date of completing this form
MM
/
DD
/
YYYY
By typing your name here you are attesting that all  your answers are true to the best of your knowledge.
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