INTAKE FORM AROMATHERAPY - victorie-inc.us

1 What is today s appointment for? How long have you had this problem? How do you think your problem began? What aggravates your problem? Does anything give you relief from your problem? 03/01/2013 Victorie Inc. Client INTAKE Form Page 1 of 4 CLIENT INFORMATION Name: Address: City: State: Zip: Phone: Mobile: e-Mail: DOB: Sex: M F Occupation: Emergency Contact: Contact Phone: PRIMARY HEALTH CARE PROVIDER (PHCP) PHCP Name: PHCP Address: City: State: Zip: PHCP Phone Number: Telephone #:Permission to Consult with PHCP? YES NO(please initial if yes) CURRENT HEALTH Have you ever had AROMATHERAPY ? YES NO (if yes please answer below)What was your appointment for? Date of last appointment: Please list any allergies you have (medications, plants, nuts, etc): Please list any prescription or over the counter medications you are taking and why: Victorie Inc. Aromatherapie Client INTAKE Form03/01/2013 Victorie Inc. Client INTAKE Form Page 2 of 4 MEDICAL HISTORY Please check any medical conditions you currently have or have had in the past 2 years.

2 Musculo-Skeletal Headaches Joint stiffness/swelling Muscle Spasms/cramps Strains/sprains Back, hip pain Shoulder, neck, arm, hand pain Carpal Tunnel Leg, foot pain Jaw pain/TMJ Tendonitis /Bursitits Arthritis Bone or joint disease Other: Circulatory and Respiratory Dizziness Shortness of breath Fainting Cold feet or hands Swollen ankles Pressure sores Varicose veins Stroke Heart condition Allergies Sinus problems Asthma High blood pressure Low blood pressure Other:_____ Skin Rashes Allergies Athlete s Foot Warts Moles Acne Other:_____ Digestive Nervous stomach Indigestion Constipation Intestinal gas/bloating Diarrhea Diverticulitis Irritable bowel syndrome Crohn s Disease Colitis Other:_____ Nervous System Numbness/tingling Twitching of face Fatigue Chronic pain Sleep disorders Ulcers Paralysis Herpes/shingles Cerebral Palsy Epilepsy Chronic Fatigue Syndrome Multiple Sclerosis Muscular Dystrophy Parkinson s disease Spinal cord injury Other: _____ Reproductive System Pregnancy: Current Previous PMS Menopause Pelvic Inflammatory Disease Endometriosis Hysterectomy Fertility concerns Prostate problems Other Loss of appetite Forgetfulness Confusion Depression Difficulty concentrating Diabetes Fibromyalgia Cancer Infectious disease (please list) _____ Surgeries_____ Other:_____ Please list any medical conditions in your family.

3 03/01/2013 Victorie Inc. Client INTAKE Form Page 3 of 4 AROMATHERAPY SERVICES Please check any areas you would like to work on. Fibromyalgia Whiplash Muscle Pain & Tension Sciatica Sprains/Strains Carpal Tunnel Arthritis Headache Anxiety Circulation Immune Systems PMS Reproductive Cosmetic IBS Constipation Nausea Cold Asthma Sinus Menopausal Acne Diverticulitis Indigestion Fatigue Sleep Disorders PID Prostate Pregnancy Loss of appetite Forgetfulness Depression Concentration OtherWhat scents do you prefer? (all that apply) Floral Citrus Fruity Woodsy Earthy Savory Spicy Sweet Fresh Grassy Musky SmokeyWhat methods of AROMATHERAPY do you prefer? (all that apply) Inhalation Massage Diffusion Compress Aromatic Spritzers Lotions, Creams, etc. Spa TreatmentList 5 words to describe how you are feeling today: List 5 words to describe your lifestyle: List 5 words to describe how you desire your day to be: What are your sleep patterns? 03/01/2013 Victorie Inc. Client INTAKE Form Page 4 of 4 AROMATHERAPY CONSENT FORMI understand the primary function of AROMATHERAPY is to enhance my overall well being and work in correlation with any current treatments is am currently using.

4 I understand the benefits and contraindications of AROMATHERAPY . It is to be used as a substitute for medical treatments. Aromatherapists do not diagnose, prescribe medications or perform chiropractic adjustment services. I have answered the above questions honestly and accurately. I have informed my aromatherapist of any current o r past medical conditions and concerns that I may have. I will inform my therapist if a new condition arises or any changes with an existing condition. I hereby release and agree that Victorie Inc. Aromath rapie - a division of Victorie Inc. is not responsible for claims for injuries, damages, losses, death, costs, and expenses of all kinds, including legal fees, in any way arising from or related to AROMATHERAPY treatments received. Client Signature Date CANCELLATIONS: Your business is valued an d your cooperation i s appreciated. We are making a commitment t o you to guarantee your appointment time and refusing all other requests once you have made the appointment.

5 A 24-hour cancellation notice is required for any scheduled appointments including gift certificate sessions. Missed or no-show appointments will result i n you being charged the full amount of the session booked unless the appointment can be filled. Depending on our booking schedule, late appointments may not receive the full session time allotted for the treatment service booked: Full payment is required. Emergency cancellations are determined by the Aromatherapist discretion. Client Signature Date OFFICE USE Personal Aroma Profile: Intention: Blend Name: Affirmation: Formulation: Application: Fragrance Categories:Floral Citrus Herbaceous Woodsy Earthy Spicy Exotic