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.
Name
Gender
Current age
Allergies / Sensitivities - Please list any known allergies and sensitivities, and any plant aromas that you dislike
Medical history - please tick all that apply
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
No pain
Extreme pain
Clear selection
For women - please tick all that are relevant
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
Stress : Please indicate on a scale of 0 (no stress) to 10 (maximum stress) what your highest daily stress level is
No stress
Maximum stress
Clear selection
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
Submit
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