Consultation Form – Aromatherapy
Personal Details: 
Client Name:	
Age Group: Under 20__ 20-30__  30-40__  40-50__  50-60__  60+ __
No. of children (if applicable): 

Medical Details
Doctors Name: 
Address & Ph. Num: 
Last Visit/Reason: 
Receiving any other treatment:

Medical History:
Current Medication: 
Vitamins/Pills: 
Herbal Remedies: 
Recent Surgery: 
Injuries: 
Falls: 
Pregnant: 

Do you or your family suffer from any of the following:
Diabetes__ High/Low blood pressure__  Asthma__  Heart condition__  Cancer__
Kidney problems__ Back problems__    Any Allergies__

Contraindications requiring medical permission:
Pregnancy (use only mandarin)__  	 Haemophilia__ 
Medical oedema__ 			 Osteoporosis__
Arthritis__ 				 Nervous/ Psychotic conditions__
Epilepsy__ 				 Recent operations__
Diabetes__ 				 Asthma__ 
Bells Palsy__ 				 Trapped/Pinched nerve(eg.sciatica)__ 
Inflamed nerve__ 			 Cancer__
Spastic conditions__  			 Kidney infections__ 
Hormonal implants__ 			 Undiagnosed pain__
Acute rheumatism__ 			 When taking prescribed medication__ 
Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)__ 
Any condition already being treated by a GP or another complementary practitioner__ 
Any dysfunction of the nervous system (e.g. Multiple Sclerosis, Parkinson’s disease, Motor Neurone disease)__ 

Contraindications that restrict treatment
Fever__ 			   Abrasions__ 
Infectious/contagious diseases__   Recent Fractures (minimum 3 months)__ 
Diarrhoea and vomiting__ 	   Sunburn __
Any known allergies__ 		   Cervical spondylitis__ 
Undiagnosed lumps/bumps__ 	   Inflammation__ 		
Cuts__ 				   Hernia __
Severe bruising__ 		   Varicose Veins __
Skin Diseases__ 		   Pregnancy (abdomen)__ 
Localised swelling__ 		   Breast Feeding__ 
Haematoma__ 			   Whiplash__ 
Slipped disc__ 			   Gastric ulcers__ 
After a heavy meal__  		   Hypersensitive skin__ 
Abdomen (first few days of menstruation depending how the client feels)__ 
Scar tissue (2 years for major operation, 6 months for a small scar __
Under influence of alcohol or recreational drugs __

Written Permission Required by:
GP/Specialist__   Informed Consent__ 
Either of which should be attached to the consultation form. 

Personal Information (select if/where appropriate):
Muscular/Skeletal problems: Back__  Aches/Pains__ Stiff Joints__ Headaches__
Digestive problems: Constipation__ Bloating__ Liver/Gall bladder__ Stomach 
Circulation: Heart__ Blood Pressure__ Fluid retention__ Tired legs__ Varicose veins__ Cellulite__ Kidney problems__ Cold hands and feet__
Gynaecological: Irregular periods__ P.M.T__ Menopause__ H.R.T__ Pill__ Coil__  Other ____________
Nervous system: Migraine__ Tension__Stress__ Depression__
Immune System: Prone to infections__ Sore throats__ Colds__ Chest__ Sinuses__
Do you have a balanced diet?: Yes__ No__
If No, please elaborate:  
Do you eat in a hurry? 
Sleep patterns: Good__ Poor__ Average number of hours: 
Ability to relax: Good__ Moderate__ Poor__
Do you see natural daylight in your workplace? 
Do you work at a computer? 
Do you exercise regularly Yes__ No__ 
Do you smoke?: Yes__ No__ 
Alcohol Intake?: Daily__ Weekly__ Rarely__ Never__
How much water do you drink a day? 
How much tea/coffee per day? 
Stress Levels: scale of 1 to 10
At home:	At work: 

Client contraindications have been checked against the safety data for each oil prior to treatment? Yes__ No __

Student/Therapist Signature:

Client Signature:   					Date: