Aromatherapist: CLIENT RECORD. Personal Information: Name: D.O.B Occupation: Address: Telephone: Marital Status: Dependents: Doctor: Doctor Informed?

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CLIENT RECORD Personal Information: Name: D.O.B Occupation: Address: Telephone: Marital Status: Dependents: Doctor: Doctor Informed? Medical History: What are you doing for your health:(eg Exercise, Diet, Herbs, Vitamins, Chiropractor, Other Therapies) Medication: Have you ever had surgery? What? When? Have you ever been in a serious accident? What? When General Information: General Health (Good, Average, Poor): Energy Levels (High, Average, Poor): Stress Levels (High, Average, Low): Reason for Aromatherapy Consultation: Severity on a scale of 0 10 where 10 is the worst: Underweight/Average/Overweight/Obese: How do you relax: Body Check Heart/Circulation: Blood Pressure: ( High/Normal/Low): Varicose Veins/Thrombosis: Epilepsy: Diabetes: Thyroid problems: Allergies:(to what/ severity) Sleep Patterns: Quality of Sleep: Headaches: Asthma:

Back/Spine: Legs: Arms/Shoulders: Joints: (Arthritis, aches and pains, sciatica, chilblains, oedema, rheumatism, other) Respiratory complaints (Asthma, breathing difficulties, bronchitis, throat infection, sinusitis, colds, flu, Other: Digestive: (Constipation, indigestion, colitis, candida, Other) Urinary (Cystits, thrush, fluid retention other): Pregnancy: Menstrual Problems: PMS: Perimenopausal: Menopausal: Skin Condition: Skin Complaints (Allergies, dermataitis, eczema, psoriasis, other): Emotional Stress/Anxiety: (Depression, Headaches, Migraines, Insomnia, Tension, Other): Emotional Concerns: How are you feeling today? How would you like to feel when you leave? What do you have to do for the rest of the day? Additional Notes Treatment Aims Treatment Plan Blend Chosen: (Essential Oil, number of drops, carrier etc) Method of Application: Home Blend Chosen: (Essential Oil, number of drops, carrier etc) Method of Application:

As a professional Aromatherapist, I do not make any claim of replacing any holistic or medical therapy. I do not advise clients in any form that my treatment is superior to any other holistic or medical one, as my therapy is of a complementary nature ONLY, rather than a curative treatment in itself. I also am not a doctor and, therefore, do not advise on ANY oil for internal ingestion. Client Signature: Evaluation of Treatment

Client Aromatic Program Take Home Sheet Exclusively designed for: Blend/Synergy 1: Application Method: Blend/Synergy 2: Application Method: Safety Precautions: 1. Keep all essential oils out of the reach of children. 2. Avoid prolonged use of the same essential oils 3. Avoid application of undiluted essential oils 4. Contact your aromatherapists should you have any questions about this program. 5. To gain maximum benefit from the oils on the skin and through inhalation of the vapours, avoid washing or bathing for approximately 4 8 hours after treatment if you can. 6. Drink plenty of water to help eliminate the toxins from your body. 7. If you feel any skin irritation after treatment, wash the area immediately. 8. Any other special precautions to be taken with this blend: Your Next appointment: If you cannot keep your appointment please cancel it ahead of time. We appreciate 24 hours notice whenever possible. Our telephone Number:

Follow up Treatments: Date Conditions Blend Outcome

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