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Aromatherapy Services Client Intake Form

I. Client Information

First Name

Last Name

Date of Birth

Phone Number

Email Address

Street Address

City/Suburb

State/Province

Postal/Zip Code

Emergency Contact Name

Emergency Contact Phone Number

II. Reason for Consultation

What are your primary reasons for seeking aromatherapy services? (Please be specific.)

What are your desired outcomes from aromatherapy treatments?

Have you used aromatherapy before? If so, what were your experiences?

III. Health History

Please list any current medical conditions:

Are you currently taking any medications (prescription or over-the-counter)?

If yes, please list them:

Do you have any known allergies (skin, respiratory, food, etc.)?

If yes, please list them:

Have you had any recent surgeries or injuries?

Do you have any of the following conditions? (Please check all that apply):

Epilepsy

Asthma

High/Low Blood Pressure

Heart Conditions

Diabetes

Skin Conditions (Eczema, Psoriasis, Rosacea, etc.)

Nervous System Disorders

Cancer

Other:

Are you currently pregnant, breastfeeding, or planning to become pregnant?

If yes, please state how far along:

Do you have any sensitivities to scents?

If yes, please list them:

Do you have any mental health conditions, such as depression or anxiety?

If yes, please explain:

IV. Lifestyle and Preferences

How would you describe your stress levels?

Low

Moderate

High

What are your typical sleep patterns?

Do you engage in regular physical activity?

Do you have any specific scent preferences or aversions?

Do you have any areas of your body you would prefer to avoid during massage or topical application?

V. Aromatherapy Therapy Options

 

(Please indicate your preferences)

 

Massage:

Full Body Massage

Back, Neck, and Shoulder Massage

Hand and Foot Massage

Scalp Massage

 

Questions regarding massage suitability:

 

Do you have any muscle soreness or tension? Where?

Have you had any recent injuries that might affect a massage?

Are you comfortable with varying levels of pressure?

Inhalation:

Diffuser Therapy

Personal Inhaler

Steam Inhalation (with caution)

 

Questions regarding Inhalation suitability:

 

Do you have any respiratory conditions that might be aggravated by inhalation?

Are you comfortable with strong aromas?

Topical Application:

Lotions/Creams

Compresses

Bath Salts/Oils

Roll-on Applicators

 

Questions regarding topical application suitability:

 

Do you have any areas of sensitive skin?

Are you prone to skin reactions or rashes?

Other:

Custom Blend Creation

Aromatherapy Consultation Only

VI. Informed Consent

I understand that aromatherapy is a complementary therapy and should not replace conventional medical treatment.

I have provided accurate and complete information about my health history.

I consent to the aromatherapy treatments discussed and agree to inform the aromatherapist of any changes in my health or well-being.

I understand that a skin patch test may be required before topical application of essential oils.

I understand that reactions can occur, and I will inform the Aromatherapist of any adverse reactions immediately.

I have been informed of the potential risks and benefits of aromatherapy.

I understand that any information I provide will be kept confidential.

Client Signature

Client Intake Form Insights

Please remove this Client Intake Form Insights section before publishing.


Let's delve into a detailed analysis of the Aromatherapy Services Client Intake Form, breaking down its components and highlighting key insights:


1. Client Information Section:

Purpose: Establishes a basic profile of the client.

Insights:

  • Accurate contact information is crucial for scheduling, follow-ups, and emergencies.
  • Date of birth is essential for age-related considerations and potential contraindications.
  • Emergency contact details are vital for safety.

2. Reason for Consultation Section:

Purpose: Identifies the client's goals and expectations.

Insights:

  • Understanding the client's primary concerns allows for targeted treatment planning.
  • Clarifying desired outcomes helps manage expectations and evaluate treatment effectiveness.
  • Previous aromatherapy experience provides valuable context for tailoring the session.

3. Health History Section:


Purpose: Gathers information about the client's medical background to identify potential contraindications and ensure safety.

Insights:

  • Current medical conditions and medications are critical for identifying potential interactions with essential oils.
  • Allergies are paramount to avoid adverse reactions.
  • Specific conditions like epilepsy, asthma, and heart conditions require careful consideration and potential modifications to treatment.
  • Pregnancy and breastfeeding necessitate specialized knowledge of safe essential oil use.
  • Mental health is very important to register, as some essential oils can greatly affect people with certain mental health conditions.
  • Sensitivities to scents, although seeming minor, are very important.

4. Lifestyle and Preferences Section:


Purpose: Provides context for the client's overall well-being and personal preferences.

Insights:

  • Stress levels and sleep patterns offer insights into the client's overall health and potential areas for support.
  • Physical activity levels influence the selection of appropriate aromatherapy techniques.
  • Scent preferences and aversions are essential for creating a positive and enjoyable experience.
  • Areas of avoidance during massage or topical application ensure client comfort and prevent discomfort.

5. Aromatherapy Therapy Options Section:


Purpose: Allows the client to express preferences for different aromatherapy modalities and helps the aromatherapist assess suitability.

Insights:

  • Offering a range of options empowers the client to participate in the treatment planning process.
  • Specific questions related to each modality help identify potential contraindications and ensure safety.
  • For example, questions about muscle soreness and injuries are crucial before performing a massage.
  • Inhalation questions help to avoid triggering asthma or other respiratory issues.
  • Topical questions help to avoid skin reactions.
  • Custom blends, or consultations alone, allow for a client that might not be ready for physical treatments.

6. Informed Consent Section:


Purpose: Protects both the client and the aromatherapist by ensuring that the client understands the nature of aromatherapy and consents to treatment.

Insights:

  • Clearly stating that aromatherapy is a complementary therapy helps manage expectations and prevent misunderstandings.
  • Client acknowledgment of accurate information and consent to treatment demonstrates informed participation.
  • Addressing potential risks and benefits promotes transparency and builds trust.
  • The confidentiality clause is very important.

7. Aromatherapist Notes Section:


Purpose: Provides a record of the treatment session for future reference and continuity of care.

Insights:

  • Observations document the client's condition and responses to treatment.
  • Essential oil selections and application methods provide a detailed record of the treatment.
  • Treatment plans and post-treatment recommendations ensure continuity of care.
  • Patch test results, are very important to record.

Key Strengths of the Form:

  • Comprehensive: Covers a wide range of relevant information.
  • Safety-Focused: Prioritizes client safety by addressing potential contraindications.
  • Client-Centered: Emphasizes client preferences and participation in treatment planning.
  • Well-Organized: Presents information in a clear and logical format.
  • Detailed: The questions are designed to get very detailed answers.

Areas for Potential Enhancement:

  • Mental Health Specifics: While the form addresses mental health, consider adding specific questions about anxiety, depression, or other mental health conditions to better tailor treatments.
  • Pain Scale: If addressing pain, consider including a pain scale to quantify the client's experience.
  • Lifestyle Habits: Expand on lifestyle habits such as diet, hydration, and smoking, as these can impact overall health and well-being.
  • Digital Version: Creating a digital version of the form can streamline the intake process and improve data management.

By incorporating these insights, you can maximize the effectiveness of your client intake form and provide safe and personalized aromatherapy services.


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