Basic Content of Aromatherapy Consultation Client Intake Form

• Personal Information

  • Full Name
  • Gender
  • Date of Birth
  • Contact Details (Phone, Email)
  • Address
  • Emergency Contact and Phone Number

• Health Information

  • Current Health Status (e.g., chronic conditions, symptoms)
  • Allergy History (especially to essential oils, plants, foods, etc.)
  • Current Medications
  • Pregnancy or Lactation Status (if applicable)
  • Skin Sensitivity or Skin Concerns

• Consultation Purpose and Expectations

  • Chief Complaint (Reason for seeking aromatherapy, e.g., stress relief, sleep improvement, pain management)
  • Desired Outcomes
  • Previous Aromatherapy Experience (if any, describe effects)

• Lifestyle and Habits

  • Dietary Habits
  • Exercise Frequency
  • Stress Level Assessment
  • Sleep Quality

• Additional Information

  • Essential Oil Preferences or Contraindications
  • Consultation Date
  • Client's Signature (confirming accuracy of information)
  • Therapist's Signature