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YesNoAre you nursing?YesNoWhat are your current health goals? What would you like to change or improve for your health/ wellness? General Health and LifestyleDo you exercise regularly? Yes or No. Times per week: Length of time: Type of exercise: Do you experience any allergic reactions to any substances ( food, environmental, etc)?Yes / No. If yes, please describe:Do you currently smoke? Yes/ No. How many cigarette per day? How long have you smoke? Have you ever smoked? Yes/ No. If so, when did you quit? Rate your level of stress ( 10 being overwhelming and 1 being the mild stress )With work/ school life: With primary intimate relationships: Have you ever had a minor injuries or operations? What happened? How is your recovery? Major illness that which requires hospitalization? Are you currently under medications?If yes, Please leave the medication.YesNoAre you under the care of other health care practitioner? YesNoMedical HistoryPlease check any conditions that may apply to you. AllergiesCancerDizzinessEpilepsyFaintingFatigueHeadachesMental DisorderNervousnessNumbnessArthritisBackache / UpperBackache/LowerBroken bonesTMJ/Jaw popsMobility LimitationsSpinal CurvatureSprained tendons/musclesStiff NeckSwollen JointsPlease check if any conditions that may apply to youBelchingConstipationAbdominal PainColitisExcessive UrinationWater RetentionMenopausalHot FlashesModd SwingsIrregular cycleBreast lumpsInfertilityVaginal dischargeLower back painVenereal diseaseHeart attackHeart diseaseHigh Blood pressureLow blood pressurePain in Heart AreaPlease check any conditions that may apply to youPoor circulationSwelling of Angkles / JointsPrevious Hearts Stroke/ MurmurAsthmaEar achesEye pains, Dry/WetFailing visionGlaucomaSinus infectionSore throatSinus congestionBoilsAcneDryness ( lacking oil)ItchingVaricose veinsInflamed/sensitiveChest painDifficulty breathingDry coughPlease check any condition that may apply to you. Spitting bloodCongestionNOTE: For those of you who practice Ayurveda, you could add this part of the consultation. VariableStrongLowReaction to missing meals Anxious/ LightheadedIrritableNot SignificantTypical quantity of meals Medium / VariesLargeSmallFrequency of meals IrregularRegularEating speedQuickMediumSlowDigestion after eating Gas, bloatingHeartburnHeavy, sluggishElimination Frequency of bowel movements (BM) Less than 1x a day2/ more times a day1 time a dayBM Tendency towards Level of comfort PainfulLooseThickRespiratory System:I am experiencing Dry Nasal/ LungPassages/ CoughBurning/InflamedLungs/ Nasal/ CoughsPhlegm, congestion, wet coughSkin Recently, my skin has been: Dry, dry patchesIn different areasInflamed heatHeat rashes, rednessVery oilyAny skin irritations, rashes, acnes, boils, eczema, etc. ? Please describe: Weight I currently feel: UnderweightLosing and gaining ( Easily)OverweightTemperatureI feel: Cold a lotHot and irritatedCold and dullSleep I have been having: Difficulty SleepingDifficulty FallingNo problem (Less or excessive)Emotion Well being I feel Exhausted, restless, anxiousTired but determinedLow energyStress I have been feelingTearful/ AnxiousAngry/AggressiveLike I want to hide awayMenstruation/MenopauseRegularity Irregular/ VariableRegularQuantity of flowLight/ VariableHeavyModerate heavyEmotionsOverwhelmed / AnxiousAngry/ IrritableSluggish /InertiaInformed 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. YesNoThis site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.SUBMITThank you! Your message was sent successfully. / PreviousNextPausePlayClose
