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

Female

Male

Other:

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

Stroke

Heart attack

Angina

High blood pressure

Low blood pressure

Varicose viens

Lymphoedema

Epilepsy

Asthma

Bronchitis

Sinus issues

Chronic Obstructive Pulmonary / Airway Disease (COPD, COAD)

Arthritis

Muscle sprain / tear / pain

Back, neck or joint pain

Bone fractures

Motor vehicle or motorbike accidents, falls

Headaches

Migraines

Shingles

Parkinson's

Mutliple Sclerosis

Chronic Fatigue Syndrome

impaired memory / dementia

Bladder / kidney infections

Continence issues

Urinary frequency or urgency

Kidney stones

Indigestion

Heart burn, reflux

Nausea

Vomiting

Irritable bowel syndrome

Diabetes

Cancer

Current infection bacterial / viral / fungal

Eczema / Dermatitis

Insomnia / poor sleep quality

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

Premenstrual

Regular menstural cycle

Irregular mentrual cycle

Prementrual Syndrome (PMS)

Menstrual pain

Endometriosis

Currently pregnant - first trimester

Currently pregnant - second trimester

Currently pregant - third trimester

New mum - baby < 6 months old

Menopausal

Hot flashes / night sweats

Post-menopausal

Gynaecological surgery

For men - please tick all that are relevant

Prostate issues

Erectile dysfunction

Prostate surgery

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

Anxiety

Depression

Grief and loss

Stress

Fear

Anger

Fatigue

Irritability

Unable to concentrate

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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