Reason for Visit
What is your primary concern?
Month/Year of onset of concern:
Your idea of the cause:
What makes it feel better?
What makes it feel worse?
Are you pregnant?
Are you trying to become pregnant?
Are you breastfeeding?
Chronic Conditions (please check)
___ High Blood Pressure
___ Low Blood Pressure
___ Any seizure disorder other than epilepsy:
___ Allergies, please list:
Are you under the care of a physician? If so, please list the condition(s) you are being treated for:
Medications: Please list all medications, herbs and supplements you are taking:
Surgeries: Please list type and date of all surgeries:
Do you have other symptoms or concerns that have not been covered?
1. How much per day do you use of the following?
a) Coffee, tea, soft drinks:
d) Other drugs:
2. Please describe your current exercise regimen:
Hours per week:
[ ] No Exercise
3. How many hours of sleep do you usually get per night during the week?
4. Are there any scents that disturb you? Are there any scents that you especially enjoy?
5. Do you have allergic reactions to any scents? If so, which one(s):
Please read and sign:
I have stated all my known conditions and have answered all questions honestly. I take it upon myself to keep the practitioner updated on my health.
I understand that the consultant is not a doctor, does not diagnose, prescribe medications, prevent or treat illness, disease or any other physical or mental conditions.
I understand that this treatment is not a substitute for medical care, treatments and/or diagnosis, and it is recommended that I see a qualified professional for any physical or mental condition that I may have.
I have read and understand the safety information below, and agree to follow these guidelines.
I hold my essential oil consultant, Barbra Mousouris C.A., dba Sixth Scents Aromatherapy, harmless for any injuries or negative effects I may experience as a result of using the products I receive from this consultation.
Client Signature Date
Aromatherapist Signature Date