Clinical Aromatherapy Consultation Form
The following is our standard consultation form. It is important for us to establish your true emotional and physical health to enable us to create a blend that suits your individual needs. Be assured that your answers are treated with the strictest confidence.





General health
Please describe your general health
Are you on any prescribed medication? (if yes, please specify below) Yes No
Do you have any allergies? (if yes, please specify below) Yes No
Are you pregnant? Yes No

Circulatory system
(please indicate if you have any problems with your circulation)
Do you suffer from high or low blood pressure? Yes No
Do you have any heart problems? Yes No
Do you suffer from cold hands and/or feet? Yes No

Lymphatic system
(Please indicate if you have any problems with your lymphatic system)
Do you suffer from fluid retention? Yes No
Do you have any areas of cellulite? Yes No

Digestive system
(Please indicate if you have any problems with your digestive system)
Do you have a balanced diet? Yes No
Do you suffer from any digestive problems (such as constipation, flatulence, trapped wind, indigestion, colitis)? Yes No
Do you drink at least 8 glasses of water per day? Yes No

Reproductive system
(Please indicate if you have any problems with your reproductive system)
Do you have any fertility problems? Yes No
Do you have painful and/or irregular periods? Yes No
Do you suffer from any menopausal complaints? Yes No

Endocrine system
(Please indicate if you have any problems with your endocrine system)
Do you suffer from diabetes? Yes No
Do you have and under- or over-active thyroid? Yes No

Immune system
(Please indicate if you have any problems with your immune system)
Are you prone to frequent colds/flu? Yes No
Do you suffer from cold sores? Yes No

Respiratory system
(Please indicate if you have any problems with your respiratory system)
Do you have any respiratory problems such as bronchitis, asthma, sinisitus or any other? Yes No

Musculo-skeletal system
(Please indicate if you have any problems with your musculo-skeletal system)
Do you have any problems with your muscles and joints such as arthritis, back pain etc? Yes No

Nervous system
(Please indicate if you have any problems with your nervous system)
Do you suffer from headaches,migranes or any other problems associated with your nervous system? Yes No

Mind and emotions
(Please indicate how you are generally feeling emotionally)
Happy Content Positive
Anxious Feeling down Stressed

Other information
Please provide any additional information that may be relevant to this clinical evaluation