Health History Form (Child)
Please fill in the child's details. Please fill in as much as you feel comfortable doing so.
Contact Information & The Basics
First Name *
First Name *
Last Name *
Name of person filling in this form *
Relationship to child *
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
Health and Lifestyle
How active is the child?
Type of exercise?
Times per week?
Allergies
Click all that apply
Allergy description
Please provide details on what the child is allergic to, how long the allergies have been bothersome, triggers for allergic responses, etc.
Current Diet Choices and Restrictions
Tick all that apply
Other foods avoided?
How much water does the child drink each day?
Level of stress, and at what times
Please describe is the child happy generally, sad, detached, etc
How would you describe your child's weight at the moment?
N/A if a baby or toddler.
How would you describe the skin of your child at the moment?
Click All that May Apply. N/A if a baby or toddler.
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 child is taking for health issues / illnesses, dosages, and how long the child has been taking the prescription, etc. Some essential oils may interfere with certain medications
Daily Supplements
Please note any Vitamins, Pro-Biotics, Super Foods, etc. your child takes 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 for the child. What do you want to change or improve for 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 aromas your child is not fond of? *
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 child's day-to-day life the best? *
(Please tick all that apply)
Required
Informed Consent
Aromatherapy is an incredible healing art and science 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 the unique needs and goals of my child. 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 my child 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 my child based upon my unique needs and goals. *
Please type your name in agreeance, and indicate today's date. Please add your child's name in brackets.
Todays date is -- *
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