Custom Blended Essential Oils
Healing Therapy Client Intake Form
Date
Client Information
First Name
Last Name
Date of Birth
Street Address
City
State/Province
Postal/Zip Code
Phone Number
Email Address
Emergency Contact
First Name
Last Name
Phone Number
Reason for Consultation
What are your primary health concerns or goals for this aromatherapy session?
What specific symptoms are you experiencing?
How long have you been experiencing these symptoms?
How would you rate the severity of your symptoms (1-10, 1 being mild, 10 being severe)?
Are there any specific areas of your body where you experience discomfort or pain?
Medical History
Do you have any known allergies (including plant allergies)?
If yes, please specify.
Do you have any current medical conditions
If yes, please specify.
asthma
epilepsy
diabetes
heart conditions
high/low blood pressure
Other:
Are you currently taking any medications (prescription or over-the-counter), including herbal supplements?
If yes, please list them.
Have you had any recent surgeries or hospitalizations?
Are you pregnant, breastfeeding, or planning to become pregnant?
Do you have any skin sensitivities or conditions (e.g., eczema, psoriasis, rosacea)?
Do you have a history of seizures?
Do you have any mental health conditions?
Do you have any nerve damage, or nerve related conditions?
Lifestyle & Preferences
What is your typical diet?
How much water do you drink daily?
How would you describe your stress levels (1-10, 1 being totally relaxed, 10 being extremely stressed)?
What are your sleep patterns like?
Do you exercise regularly?
If so, what type and how often?
Are there any specific scents or aromas that you particularly enjoy or dislike?
Do you have any sensitivities to heat or cold?
Do you have any religious or cultural restrictions that may affect your treatment?
Therapy Options & Suitability
Please indicate your interest in the following therapies and answer the associated questions to determine suitability.
1. Aromatic Massage
Are you comfortable with receiving a massage?
Are there any areas of your body that you would prefer to avoid during the massage?
Do you have any current injuries or areas of inflammation that should be avoided during massage?
Are you taking any blood thinning medications?
2. Topical Application (Lotions, Creams, Compresses)
Are you comfortable with topical application of essential oil blends?
Do you have any known skin sensitivities?
Would you prefer warm or cool compresses?
warm compresses
cool compresses
Are you comfortable with the application of oils to your face?
3. Inhalation (Diffusers, Steam Inhalation, Inhalers)
Do you have any respiratory conditions (e.g., asthma, COPD)?
Are you sensitive to strong scents?
Do you have any issues with congestion, or sinus problems?
Are you comfortable with steam inhalation?
4. Bath Blends
Do you have any skin sensitivities or conditions that might be aggravated by a bath?
Do you have any issues with dizziness or balance?
Do you have any limitations regarding water temperature?
Do you have a bath tub available?
5. Personal Inhalers/Aroma Jewelry
Are you interested in a portable aromatherapy option?
Do you have any sensitivities to metals or other materials used in jewelry?
6. Custom Blended Diffuser Blends
Are there any specific scents or aromas you wish to avoid?
What is the size of the room you intend to diffuse in?
Do you have children or pets in the home?
Client Consent
I understand that aromatherapy is a complementary therapy and is not a substitute for conventional medical treatment.
I have provided accurate and complete information about my health and medical history.
I understand that the essential oils used in my treatment will be selected based on my individual needs and preferences.
I understand that I am responsible for informing the therapist of any changes in my health or medications.
I understand that some essential oils can cause skin irritation or allergic reactions. I will inform the therapist immediately if I experience any adverse reactions.
I consent to the use of my personal information for the purpose of my aromatherapy treatment.
Client Signature
Form Template Insight
Form Template Insight
Please remove this form template insight section before publishing.
Important Disclaimer: This intake form is for informational purposes only and does not constitute medical advice. It is essential to consult with a qualified healthcare professional before starting any new treatment, especially if you have any underlying health conditions.
This client intake form is designed to be comprehensive and prioritize client safety and effective treatment. Here's a detailed breakdown of its key aspects and insights:
1. Comprehensive Client Information:
Purpose: Establishes a clear client profile for record-keeping, communication, and emergency situations.
Insight: Accurate contact information is crucial for follow-up and in case of adverse reactions. Emergency contact details provide a safety net.
2. Detailed Reason for Consultation:
Purpose: Allows the therapist to understand the client's primary concerns and goals, guiding the treatment plan.
Insight: The use of a pain scale (1-10) provides a quantifiable measure of symptom severity, aiding in tracking progress. Asking about the duration of symptoms helps identify chronic vs. acute issues.
3. Thorough Medical History:
Purpose: Identifies potential contraindications and ensures client safety.
Insight:
- Allergies: Essential oils are potent plant extracts; allergies are a major concern.
- Medical Conditions: Certain conditions (e.g., epilepsy, heart conditions) require caution with specific essential oils.
- Medications: Drug interactions are possible; some essential oils can affect medication efficacy.
- Pregnancy/Breastfeeding: Many essential oils are contraindicated during these stages.
- Skin Sensitivities: Prevents adverse skin reactions.
- Nerve damage: Some oils can cause further damage to sensitive nerves.
- Mental health conditions: some oils can interact negatively with mental health medications, or exacerbate existing conditions.
Key Consideration: This section is critical for risk assessment and ensures responsible practice.
4. Lifestyle & Preferences:
Purpose: Provides a holistic view of the client's health and well-being, informing personalized treatment.
Insight:
- Diet, hydration, sleep, and stress levels significantly impact overall health and can influence treatment outcomes.
- Scent preferences are crucial for creating a positive and effective aromatherapy experience.
- Heat and cold sensitivities are important for therapies like compresses or baths.
- Religious or cultural restrictions must be respected to create a safe and comfortable environment.
5. Therapy Options & Suitability:
Purpose: Allows the client to explore various aromatherapy modalities and ensures their suitability for each.
Insight:
- Each therapy option has specific contraindications and considerations.
- Asking targeted questions about comfort levels, sensitivities, and existing conditions ensures informed consent and safe practice.
- It gives the client agency in the process, and allows them to choose the therapy that best suits their needs.
Specific Therapy Insights:
- Aromatic Massage: Blood thinners, injuries, and discomfort are key concerns.
- Topical Application: Skin sensitivities are paramount.
- Inhalation: Respiratory conditions and scent sensitivities are critical.
- Bath Blends: Skin sensitivities, balance issues, and water temperature preferences are important.
- Personal Inhalers/Aroma Jewelry: Metal sensitivities and portability needs are considered.
- Custom Blended Diffuser Blends: Room size, pets, and children are taken into account.
6. Client Consent:
Purpose: Ensures the client understands the nature of aromatherapy and their responsibilities.
Insight:
- Clearly states that aromatherapy is a complementary therapy, not a replacement for medical treatment.
- Emphasizes the importance of accurate information and ongoing communication.
- Acknowledges the potential for adverse reactions and the client's responsibility to report them.
- Provides legal protection for the practitioner.
7. Therapist Notes:
Purpose: Provides a record of the treatment plan, observations, and follow-up recommendations.
Insight:
- Ensures continuity of care and facilitates tracking progress.
- Serves as a valuable resource for future consultations.
- Helps with refining treatment protocols, and documenting the efficacy of the chosen blends.
Overall Strengths:
- Comprehensive: Covers a wide range of client information and therapy options.
- Safety-Focused: Prioritizes client safety by identifying potential contraindications.
- Client-Centered: Encourages client participation and informed consent.
- Holistic: Considers the client's physical, emotional, and lifestyle factors.
- Well Organized: The form is divided into logical sections, making it easy to use.
Potential Improvements:
- Consider adding a section for the client to list their desired emotional or mental state. For example, "What emotional state would you like to achieve from this therapy?".
- Add a section about the client's current emotional state.
- Add a section about the clients occupation, as some occupations can add to certain conditions.
- Consider adding a section for the client to rate their current energy levels.
- Clarify the distinction between "allergies" and "sensitivities" to ensure accurate reporting.
By using this detailed intake form, aromatherapy practitioners can provide safe, effective, and personalized treatments that meet the unique needs of each client.
To configure an element, select it on the form.