To register with the practice please complete the following questionaire

Name*  
D.O.B*
DD MM YYYY
Sex
Male Female
Weight
(please specify kilos or stones)

Height
(please specify
feet or cm)
Address*  
Email*  
Telephone*  

Are you allergic to anything?
e.g wheat, nuts 		Yes No

If yes please specify
 
Occupation
(Identify key areas such as stress in the workplace or working with harmful toxins)
Are you pregnant?
Yes No
If pregnant, how many months
Do you smoke?
Yes No
If you smoke, how many a day?
Do you drink?
Yes No
If so how many units a week (175ml glass of wine is 1.17 units)

 
Have you visited an Aromatherapist before?

Yes No
  If you visited an Aromatherapist, what was it for and what was your experience?


Please give an overview of your problem/ issue?
How long have you been experiencing your problem/ issue?

Are you taking any existing medication or seeing a therapist?

Yes No


Are there any aromas you actively dislike? (e.g. I hate the smell of oranges)


Please indicate your preferences of the following

Fruity ok good love it
Woody ok good love it
Floral  ok good love it
Minty ok good love it
Herbal ok good love it
Spicy  ok good love it


Please indicate which of the following is your favourite

The Beach ok good love it
An Orchard ok good love it
A Flower Garden ok good love it
The Riverbank ok good love it
A Mountainside ok good love it
A Forest  ok good love it
A City Park  ok good love it


How would you describe yourself?


For your specific problem/ issue please indicate which areas apply
Detox cellulite low energy poor memory/ concentration acne frequent fungal infections    
Joint Care painfull joints swollen joints stiffness one area on body multiple areas on body worse on waking
Stress more tired that usual irritable, poor sleep feeling tired on waking working long hours frequent headaches
Depression tearful feelings of dread anxious grief sleeping more than normal not sleeping well
Digestion constipation loose bowel movements nausea bloating IBS    
Immune System frequent colds frequent fungal infections                
Stretch Marks and Scarring recent wound still healing stretch marks old scarring            
Study Aid lacking in motivation poor memory                
Sensual Aid poor libedo stimulatory problems                
Other - Please state