AROMATHERAPY CLIENT INTAKE FORMS
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1 AROMATHERAPY CLIENT INTAKE FORMS 109
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3 ACP-1 ACTIVITY: AROMATHERAPY CLIENT INTAKE FORM In this course, we covered making aromatic and therapeutic blends for treating sicknesses and diseases. You will find most people are interested in finding answers to their health concerns and are seeking an alternative to prescribed medicines. As you have learned, therapeutic grade essential oils do offer us a great option to meds! For those who would like to pursue a career in aromatherapy as a Certified Aromatherapist, performing a case study will give you an opportunity to start your practice. In this activity, you will use this intake form just like you would if you were practicing clinical aromatherapy. Use this form to collect data for your client (this can be yourself or a friend). It is important to get as much health history as possible in guiding users on which essential oils will benefit them. With this information, write up a case study (using the 2nd form that follows) for a prescribed treatment plan using essential oils. Feel free to ad lib if you do not have a health issue or a friend willing to volunteer. Aromatherapy Intake Form First Name: Date of Birth: Address: / / Last Name: City: State: Zip: Phone Number: 1. How would you describe your overall health?
4 2. What are you hoping essential oils can do for your health? 3. Do you have any chronic illnesses? If yes, what type of condition? 4. How long have you been aware of this condition? 5. What type of treatment(s) have you tried? 6. What has helped?
5 7. What symptoms are most difficult for you? 8. Do you have any acute conditions you would like to address? 9. Please list any allergies: 10. Are you pregnant or trying to become pregnant? Yes No 11. Do you have epilepsy? Yes No 12. Do you have high/low blood pressure? Yes No 13. Which oils or aromas are you drawn to?
6 14. Do any oils or aromas disturb you? 15. Are you under the care of a physician? If so, please list the condition(s) you are being treated for: 16. Please list any medications you are taking: Since essential oils should not be used under certain circumstances, I affirm that I have truthfully answered all questions pertaining to my health on the Aromatherapy Intake Form. Please sign below. Signature: Date: / /
7 Aromatherapy Clinical Practice Intake Notes For your aromatherapy clinical practice, you will need to make intake notes for each client. Use this form as a guide to help you get started. Client Profile & Lifestyle Here you can write a summary of what is covered in the consultation form. You should be able to see from the client s lifestyle what is causing any particular problem, i.e. a lot of driving could lead to backache. You need detailed information about the client to treat them holistically. Treatment Plan Here you can explain what the client would like you to help them with. For example, do they have a bad back? You would choose oils that help relieve aches and pains, or are antispasmodic. Will your plan be focusing on any particular area of the body?
8 Treatment One Refer to Lesson 10: Carrier Oils for determining which oils are best for certain conditions. Details of How The Treatment Was Conducted What methods were recommended in essential oil usage? Details of How The Client Felt Before, During and After The Treatment Here you can point out the client s disposition, and/or any physical/emotional problems they have
9 Home Care and After Care Advice Note recommended methods for self-treatments i.e. baths, compresses, etc. with quantities of oil and frequency of use. Advise client of normal reactions to treatments such as feeling tired, etc. Inform client of any aftereffects of oils i.e. phototoxic so stay out of the sun. Reflective Practice How did you perform as a therapist? Were you nervous/confident?
10 Treatment Follow Up Check your consultation form for any changes since initial visit. Make sure that the client has not become pregnant, has had any bad reactions, or is on any new medications, etc. Overall Conclusion Did your recommendations accomplish their goals? Did you learn anything from treating this client? Would you have done anything differently?
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