Aromatherapy Consultation Online Booking Form
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Aromatherapy Consultation Booking Form
This is a confidential health questionnaire that will only be read by Annie. Please answer each question honestly so that the healing support offfered is safe and tailored for you. Please refer to the disclaimer on the website.
Allergies / Sensitivities - Please list any known allergies and sensitivities, and any plant aromas that you dislike
Medical history - please tick all that apply
High blood pressure
Low blood pressure
Chronic Obstructive Pulmonary / Airway Disease (COPD, COAD)
Muscle sprain / tear / pain
Back, neck or joint pain
Motor vehicle or motorbike accidents, falls
Chronic Fatigue Syndrome
impaired memory / dementia
Bladder / kidney infections
Urinary frequency or urgency
Heart burn, reflux
Irritable bowel syndrome
Current infection bacterial / viral / fungal
Eczema / Dermatitis
Insomnia / poor sleep quality
Medical history in depth - please provide more information on each item you ticked and current treatment.
Pain: Please indicate the intensity of pain on a scale of 0 (no pain) to 10 extreme pain
For women - please tick all that are relevant
Regular menstural cycle
Irregular mentrual cycle
Prementrual Syndrome (PMS)
Currently pregnant - first trimester
Currently pregnant - second trimester
Currently pregant - third trimester
New mum - baby < 6 months old
Hot flashes / night sweats
For men - please tick all that are relevant
Surgical History - If you have had any surgical procedures, please list and detail any current management.
Emotional and mental well-being - please tick all that are relevant
Grief and loss
Unable to concentrate
Stress : Please indicate on a scale of 0 (no stress) to 10 (maximum stress) what your highest daily stress level is
Current medication - please list any current medications, supplements / vitamins and natural remedies including essential oils
Please advise if you are currently seeing other health professionals, and the types of treatment you are receiving
Please list any preferences for plant-based fragrances
Please list your main health goals / reasons for booking this consultation
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