Health History Form (Adult)
Please fill in as much as this as you feel comfortable doing so.
Contact Information & The Basics
First Name *
Last Name *
Mailing Adress (for product to be sent, if applicable) *
Phone Number
Email *
Would you like to be added to our mailing list? *
Birth Date
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Gender
Partner Status
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Do you have children?
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Health and Lifestyle
Do you exercise regularly?
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Type of exercise?
Times per week?
Allergies
Click all that apply
Allergy description
Please provide details on what you are allergic to, how long the allergies have been bothersome, triggers for allergic responses, etc.
Current Diet Choices and Restrictions
Tick all that apply
Any other foods that you avoid?
Do you currently smoke?
Clear selection
Have you ever smoked. If so, when did you quit and how long did you smoke for?
Do you drink caffeinated drinks? Coffee or teas.
Clear selection
If so, how much do you drink a day and at what times during the day?
Do you drink alcohol?
Clear selection
If so, how many times a week, and how much each time?
If so, what kind of alcohol do you drink?
Tick All that Applies
Clear selection
How much water do you drink each day?
Rate your level of stress (10 being overwhelming and 1 being mild stress)
What is the most stressful area of your life?
How would you describe your weight at the moment?
How would you describe your skin at the moment?
Click All that May Apply
Blood pressure?
Any Acute Health issues? Please explain:
Acute conditions are severe and sudden in onset. This could describe anything from a broken bone to an asthma attack.
Any Chronic Health issues? Please explain:
A chronic condition, is a long-developing syndrome, such as osteoporosis or asthma.
Any physical stresses? Please explain:
Any emotional or mental stresses? Please explain:
Do you have a specific spiritual practice? Please describe:
Any other issues, that should be noted?
Please check all that apply
History of Disease
Any major illnesses or hospitalizations due to sickness
Notable injuries
Broken bones, auto accidents, falls, etc
Notable surgeries
Prescription Medication
Please list medications you may be taking for health issues / illnesses, dosages, and how long you've been taking the prescription, etc. Some essential oils may interfere with certain medications
Daily Supplements
Please note any Vitamins, Pro-Biotics, Super Foods, etc. you use on a daily or regular basis. Some essential oils may interfere with certain supplements
Aromatherapy Consultation
What do you want to obtain from this experience? *
(Tick all that apply)
Required
What Are Your Current Health Goals. What do you want to change or improve for your health and wellness? *
Do you have an idea of what you are looking to have formulated, from this consultation? *
If so, have you tried other products to help with this before? *
Please provide details like what you tried and what the results were.
Physical Issues *
(Tick All that Apply)
Required
Emotional (How You Feel) // Mental (How You Think) Issues *
(Tick All that Apply)
Required
What aromas do you most enjoy? *
(Tick All that Apply)
Required
Are there any essential oils that you do not have a fondness for? *
Please note; this is just a guide, depending on the highlighted uses for an essential oil, I still may find it worthy of including in your product
As a method of application, which of these resonates with your day-to-day life the best? *
(Please tick all that apply)
Required
Female Only
Is there a possibility you are pregnant. Or, are you pregnant?
Clear selection
Are you breastfeeding?
Clear selection
Are you trying to become pregnant?
Clear selection
If so, please explain briefly how that progress is going, including hurdles being faced?
Informed Consent
Aromatherapy is an incredible healing art and scince that supports and enhances the inviduals ability to heal and maintain health. 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 undersand that my aromatherapy practitioner, Elisabeth "Libby" Vlasic, does not diagnose, prevent or treat any illness, disease, or any other physical or mental condition. Furthermore, I understand that this treatment is not a substitute for medical treatment and it is recommended that I see a qualified professional for any physical or mental condition that I may have. This consultation does not take the place of a medical evaluation. I have read the above infomation and hereby give my permission for Elisabeth "Libby" Vlasic to design an aromatic program for me based upon my unique needs and goals. *
Please type your name in agreeance, and indicate today's date
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