Consultation Form

Name

D.O.B

Phone/WhatsApp

PREFERED METHOD OF CONTACT

OCCUPATION

ADDRESS

TYPICAL WORK SCHEDULE (shift, nights, part-time, etc.)

FAMILY STATUS/LIVING ARRANGEMENTS (single, married, kids, roommates, etc.)

LIST ANY HEALTHCARE PROVIDERS YOU VISIT

LIST ANY MEDICAL CONDITIONS OR MAJOR SURGERIES PAST OR PRESENT

LIST ANY MEDICATIONS OR ALLERGIES

EXPLAIN THE PURPOSE OF YOUR VISIT/AREAS OF CONCERN

Headaches/Migraines:

Yes No

High/Low Blood Pressure:

Yes No

Back Pain

Yes No

Skin Issues:

Yes No

Digestive Issues:

Yes No

Epilepsy:

Yes No

Diabetic:

Yes No

Muscle/Joint Pain:

Yes No

Lactation

Yes No

Liver Disease:

Yes No

Recovering from an operation:

Yes No

Unrecognizable lumps or bumps:

Yes No

Do you have recent scar tissue:

Yes No

Do you have a well-balanced Healthy Diet?

Yes No

Do you exercise:

Yes No

Alcohol Consumption:

No Alcohol Moderate Heavy

Do you have any concerns that you believe are impacting your well-being?

Yes No

Have you had any treatments done in the past months?

Do you have a Sedentary lifestyle or an active one?

What kind of Hobbies and Interests do you have?

How do you feel your lifestyle impacts on your overall health and well-being? Positively or Negatively?

CONSENT TO TREATMENT:

I am consenting to an aromatherapy treatment and understand that this is not a medical treatment. No prescriptions, medical assessment, or diagnosis will be provided. I understand that the purpose of this treatment is relaxation, stress reduction, and improvement of the body’s natural functions. I am aware that I may stop treatment at any time. I have given full disclosure of any medication I am currently taking (holistic or prescribed) and of any medical conditions I agree to keep this information as up-to-date as possible.

CHAMPAKA

Consultation form