aroma rx consultation questionnaire new
TRANSCRIPT
O R G A N I C S
Aroma Rx Client Intake Form
greenenvee.com
1. I usually wake up in the morning feeling energized and it continues throughout the day ...............
2. I feel that I have a good balance between work and my personal life.............................................
3. I have a lot of patience and do not become easily irritated.............................................................
4. I am always able to remember things that are important...............................................................
5. I feel that I have a clear mind and am able to concentrate easily...................................................
6. I rarely suffer from head tension such as headaches and migraines..............................................
7. I often feel relaxed and stress free ...............................................................................................
8. I like to keep everything neat and clean.......................................................................................
9. I tend to find good balance between work and recreation............................................................
10. I am able to control my emotions and do not have emotional 'breakdowns'.................................
11. I am able to fall asleep and stay asleep, feeling rested when I awake in the morning...................
12. I take enough time for myself which allows me to relax...............................................................
13. I respect other people's opinions and don't have a problem admitting that I am wrong................
14. I am able to make decisions easily...............................................................................................
15. I have a positive outlook and do not worry about what can't be controlled or changed................
16. I meditate because I feel it is important.......................................................................................
17. I am organized and keep on a specific timeline...........................................................................
18. I feel that my life is balanced and I am able to do things that I enjoy............................................
Directions: Respond to these statements with an absolute YES, NO, or SOMETIMES. Don’t think about them too much. Your answers should be intuitive and spontaneous.
Clients Name
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
Emotional Snapshot Questions
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
NO SOMETIMES YES
AWAKE / BRAZILIAN ORANGE & LITSEA
REFRESH / TUNISIAN ROSEMARY & PEPPERMINT
BALANCE / SRI LANKAN LEMONGRASS
RELAX / FRENCH LAVENDER & CHAMOMILE
STABILIZE / INDONESIAN PATCHOULI & ORANGE
ZEN / EGYPTIAN MYRRH & SANDALWOOD
Aroma Rx Evaluation Criteria: If you answered NO or SOMETIMES to 2 or more questions in any category, you may be in need of emotional balancing in that aroma category. Because unbalanced emotional states can manifest itself into physical discomfort, illness, or even disease, it is important to use aromatherapy as part of your daily routine for health and vitality. An array of aromatherapy products are listed on the back. These products are designed to help re-balance your mind, body, & spirit.
RecommendedAction
Needs Balancing
Needs Balancing
Needs Balancing
Needs Balancing
Needs Balancing
Needs Balancing
Date
O R G A N I C S
Therapist Recommendations
AWAKE / BRAZILIAN ORANGE & LITSEA
REFRESH / TUNISIAN ROSEMARY & PEPPERMINT
BALANCE / SRI LANKAN LEMONGRASS
RELAX / FRENCH LAVENDER & CHAMOMILE
STABILIZE / INDONESIAN PATCHOULI & ORANGE
ZEN / EGYPTIAN MYRRH & SANDALWOOD
ORGANIC CANESUGAR SCRUB
MOISTURIZINGBODY LOTION
REJUVENATINGBODY OIL
AROMA MISTRx
SYNERGISTICESSENTIAL OIL
MOISTURIZINGBODY WASH
MOISTURIZINGBAR SOAP
ORGANIC CANESUGAR SCRUB
MOISTURIZINGBODY LOTION
REJUVENATINGBODY OIL
AROMA MISTRx
SYNERGISTICESSENTIAL OIL
MOISTURIZINGBODY WASH
MOISTURIZINGBAR SOAP
ORGANIC CANESUGAR SCRUB
MOISTURIZINGBODY LOTION
REJUVENATINGBODY OIL
AROMA MISTRx
SYNERGISTICESSENTIAL OIL
MOISTURIZINGBODY WASH
MOISTURIZINGBAR SOAP
ORGANIC CANESUGAR SCRUB
MOISTURIZINGBODY LOTION
REJUVENATINGBODY OIL
AROMA MISTRx
SYNERGISTICESSENTIAL OIL
MOISTURIZINGBODY WASH
MOISTURIZINGBAR SOAP
ORGANIC CANESUGAR SCRUB
MOISTURIZINGBODY LOTION
REJUVENATINGBODY OIL
AROMA MISTRx
SYNERGISTICESSENTIAL OIL
MOISTURIZINGBODY WASH
MOISTURIZINGBAR SOAP
ORGANIC CANESUGAR SCRUB
MOISTURIZINGBODY LOTION
REJUVENATINGBODY OIL
AROMA MISTRx
SYNERGISTICESSENTIAL OIL
MOISTURIZINGBODY WASH
MOISTURIZINGBAR SOAP
ORGANIC CANESUGAR SCRUB
MOISTURIZINGBODY LOTION
REJUVENATINGBODY OIL
AROMA MISTRx
SYNERGISTICESSENTIAL OIL
MOISTURIZINGBODY WASH