PERSONAL DETAILS
PERSONAL DETAILS | |
|Surname: | |Consultation Date: | / / |
|First Name(s): | | |
|Title: | |Telephone – daytime: | |
|Address: | | - evening: | |
| | |Gender: |[pic][pic] |
| | |Date of Birth: | / / |
|Postcode: | |Occupation: | |
|Email Address: | | |
|Civil Status: | |Emergency Contact info |
| | |(incase of an emergency during therapy session) |
|Children + Ages: | | |
|GP Name: | |Name: | |
|GP Address: | |Telephone Number: | |
| | |Relationship to Contact: | |
|Can we contact you with promotional messages? |[pic][pic][pic] |
| |
|THERAPY DETAILS |
|Reason(s) for wanting Aromatherapy: | |
|Expectations from the treatment: | |
|Any areas of your body that you generally do not like being | |
|touched? (e.g. feet, face) | |
|Which kind of aromas do you like? | |
|Which kind of aromas do you not like? | |
|Have you previously had Aromatherapy or any other holistic |[pic][pic] |If Yes, What treatment & When| |
|treatment? | |did you have it? | |
|Are you currently having any other forms of holistic (alternative / |[pic][pic] |If Yes, please give | |
|complimentary) treatments? | |details: | |
|MEDICAL & SURGICAL HISTORY |
|Please provide Medical & Surgical History: |Condition/Surgery |Date diagnosed / performed |
|(include details of condition / surgery and date | | |
|diagnosed / surgery performed) | | |
| |1. | |
| |2. | |
|Details any current conditions currently being treated by your doctor, therapist | |
|or yourself: | |
|Details of any current medication, treatments or alternative therapies: | |
|Details of any allergies that you have: | |
|Details of problem areas of your body: |Onset |Frequency |Duration |
| |(when does it usually start?) |(how often do you get it?)|(how long does it go on for?) |
|1. | | | |
|2. | | | |
|Have you had any operations in the last year? |[pic][pic] |
| |If Yes then |What Operation? | |
| | |When? | |
|Are you currently receiving any other professional | |
|treatments for your body? |[pic][pic][pic] |
|If so, please give details: | |
| |
| |
|Female Clients Only |
|Date of Last Period: | / / | |
|Do you suffer with PMT? |[pic][pic] |If Yes, How does it affect you? | |
|Do you suffer from menstrual pains? |[pic][pic] | |
|Are you menopausal? |[pic][pic] |If Yes, How does it affect you? | |
|Are you pregnant? |[pic][pic] |If Yes, How many weeks? | |
| |
|Please indicate if you currently, or have ever, suffered from any of the conditions below (tick as many boxes as apply to you): |
|Skin Conditions |Circulation |Other Conditions |Digestive |
| | |[pic][pic][pic][pic][pic][pic][pi| |
|[pic] |[pic] |c][pic][pic][pic] |[pic] |
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|[pic] | | | |
| | |Joint and Muscle Problems |Mind and Mood |
| | |[pic][pic][pic][pic][pic][pic] | |
| | | |[pic] |
| | | |[pic] |
| | | |[pic] |
| | | |[pic] |
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|Any other diagnosed condition (please specify): |
|LIFESTYLE |
|Lifestyle |[pic][pic] |
|What is your appetite like? |[pic][pic][pic][pic] |
|Do you have a well balanced diet? |[pic][pic] |
|Do you eat meals regularly each day? |[pic][pic] |
|Do you have regular bowel movements? |[pic][pic] |
|Do you take any food / vitamin supplements? |[pic][pic] |If Yes, which ones? |
|How many cups/glasses of water and non-caffeinated drinks do you |[pic][pic][pic][pic] |
|drink per day? | |
|How many cups/glasses of caffeinated (e.g. tea, coffee) drinks do |[pic][pic][pic][pic] |
|you drink per day? | |
|Do you drink alcohol? |[pic][pic] |If Yes, approx. how many units per week? |
|Do you smoke? |[pic][pic] |If Yes, approx. how many cigarettes per day? |
|Do you Exercise regularly? |[pic][pic] |If Yes, what type and how often? |
|General Stress Level (1-10) [10=highest] | |
|Your work hours per week (on average)? | |
|Percentage of your work find stressful? |[pic][pic][pic][pic] |
|Hobbies / Interests: | |
|How easy do you find it to relax? |[pic][pic][pic][pic] |
|What do you do to relax? | |
|How well do you sleep? |[pic][pic][pic][pic] |
|What is your average hours sleep per night? |[pic][pic][pic][pic] |
|What is your general body skin type? |[pic][pic][pic][pic][pic] |
| |
|CLIENT OBJECTIVES FOR INITIAL TREATMENT (to be completed by therapist) |
|[pic][pic][pic][pic] |
|Key Aims of Treatment: |
|1. |
|2. |
|3. |
|Cross Referencing: |
|Main Condition (1) |Secondary Condition (2) |Third Condition (3) |
|Top |
|Carrier Oils |Amount (ml) |Essential Oils |Amount (no. of drops) |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|Treatment Plan: |
| |
| |
| |
DECLARATION: “I confirm that the information given above is correct and that to my knowledge, I have not withheld any information that may be deemed relevant to my treatment. I will notify the therapist of any future changes in my health before receiving further treatments. I accept full responsibility for any problems arising from my omissions on this form, including relevant health conditions, medications and ongoing medical treatments.”
PLEASE NOTE: All information held about clients is held securely in strictest confidence.
|Client Signature: |Date: / / |
|Therapist Signature: |Date: / / |
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