Name * First Name Last Name Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country DOB MM DD YYYY Sex Email * MEDICAL HISTORY Current Chronic Conditions: Current Acute Conditions: Most Problematic Symtpoms: Treatments: Current Medications: Recent Surgeries: Allergies: Are you Pregnant? Yes No Trying? Yes No Breastfeeding? Yes No Do you have epilepsy? High/low blood pressure? Hours sleep per night: Exercise Activities: Hours per week: AROMATHERAPY Reason for visit: Most pleasant scents/oils: Least pleasant scents/oils: Allergies/Irritations to any scents/oils: Other information/concerns: Thank you for submitting your form, we will be in touch soon! Aromatherapy Intake Form
