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Consultation Form

Natural Healing with Natural Products

Is there a possibility that you are pregnant?
Are you nursing?
Do you exercise regularly? Yes or No. Times per week: Length of time: Type of exercise:
Yes / No. If yes, please describe:
How long have you smoke? Have you ever smoked? Yes/ No. If so, when did you quit?
With work/ school life: With primary intimate relationships:
What happened? How is your recovery?
Are you currently under medications?
If yes, Please leave the medication.
Are you under the care of other health care practitioner?
Medical History
Please check any conditions that may apply to you.
Please check if any conditions that may apply to you
Please check any conditions that may apply to you
Please check any condition that may apply to you.
NOTE: For those of you who practice Ayurveda, you could add this part of the consultation.
Reaction to missing meals
Typical quantity of meals
Frequency of meals
Eating speed
Digestion after eating
Frequency of bowel movements (BM)
BM Tendency towards Level of comfort
Respiratory System:
I am experiencing
Recently, my skin has been:
Please describe:
I currently feel:
I feel:
I have been having:
Emotion Well being
I feel
I have been feeling
Quantity of flow
Informed Consent
I understand that this consultation is designed to gather information so that the practitioner is able to design and create aromatic products based upon my individual needs and for the express purpose of supporting health and well- being through lifestyle changes, health habits, and healthy mental well-being. I understand that my aromatherapy practitioner ( name) does not diagnose, prevent or treat any illness, disease, or any other physical or mental condition. I understand that I am consulting this practitioner for educational purposes only, of my own free will. I understand that this treatment is not a substitute for medical treatment and it is recommended that I see a qualified professional for any physical or mental condition that I may have. I understand that any evaluation cannot determine a specific disease condition I may have and that it does not replace the diagnostic services offered by licensed physicians. I understand they will not suggest that I cease medical care I am undertaking. I understand that the decisions I make regarding my health care are my sole responsibility and I will not hold they' re responsible for the consequences of my decisions. I understand that they neither claims, nor implies, that any instruction, advice, counsel, suggestions, recommendations, services, or products he/she or his/her representatives provide, whether in person or by mail or by telephone, will cure, treat, prevent, or mitigate any disease condition ; but are provided solely for the purpose of supporting the natural function of the body systems, and to improve general health and well-being. I have read the above information and I hereby give my permission for Lindsey M. Robinson, LMT, Certified Aromatherapist to design an aromatic program for me based upon my unique need and goals.
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