Aromalyne Level 3 Diploma in Aromatherapy (VTCT)

AROMATHERAPY CONSULTATION FORM

The following information is required for your safety and to benefit your health. Whilst essential oils and massage are totally safe when administered professionally by a qualified therapist, there are certain contra-indications that require special attention.

The information that you give will treated in the strictest confidence according to the Data Protection Act. It may, however, be necessary for you to consult your GP before any aromatherapy treatment can be given.

Date of initial consultation: Client ref. No.:

GENERALName:Address:

Telephone no: Daytime: Mobile:Email address:

Date of Birth: Occupation:

MEDICALName of Doctor: Surgery:Address:

Telephone no:

Date of last visit to doctor:

MEDICAL DETAILS

The following contraindications may prevent or restrict the treatment – in circumstances where you would like medical permission but it cannot be obtained clients must give their informed consent in writing prior to the treatment.

Do you have or have you ever suffered from any of the following:

Cardiovascular conditions – thrombosis, phlebitis, hypertension, hypotension, heart conditions

Haemophilia Any condition already being treated by a GP or another complementary

practitioner

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Aromalyne Level 3 Diploma in Aromatherapy (VTCT)

Contagious skin disorder – impetigo, herpes simplex, herpes zoster or tinea corporis

Skin allergies Medical oedema Osteoporosis Nervous/psychotic conditions Epilepsy Recent operations Diarrhoea Vomiting Diabetes Asthma Any dysfunction of the nervous system – Multiple Sclerosis, Parkinson’s

Disease, Motor Neurone disease Cancer Undiagnosed pain Undiagnosed lumps When taking prescribed medication Severe varicose veins Recent head or neck injury Haemorrhage Meningitis Thrombosis Fever Contagious or infectious diseases Under the influence of alcohol or recreational drugs Skin disorders – boils, folliculitis, warts, verrucae or tinea pedis Inflammation/swelling Pregnancy (abdomen) Breast feeding Cuts/Abrasions/Bruises Scar tissue (2 years for major operation and 6 months for small scar) Sunburn Abdomen (first few days of menstruation depending on how the client feels) Hormonal implants Haematoma Recent fractures (minimum of 3 months) Hernia After a heavy meal Hypersensitive skin Neck problems Migraine

Are you currently under GP/hospital care?

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Aromalyne Level 3 Diploma in Aromatherapy (VTCT)

Current medical treatment

Current medication (list dosages)

Female clientsIs it possible you may be pregnant?If pregnant, how many months (any history of miscarriage)?Are you currently menstruating?Number of pregnancies (with dates)

GP Referral required? Yes NoClearance Letter sent Yes No Date:Clearance Letter received? Yes No Date:

GENERAL HEALTHIs your general immunity/health GOOD/AVERAGE/POOR?

Would you say your energy levels are HIGH/AVERAGE/LOW?

Would you consider your stress levels to be HIGH/AVERAGE/LOW?

Sleep patterns:

HEALTH RELATED PROBLEMSDo you suffer with any of the following:

Skin complaints:

Allergies/ Dermatitis/ Eczema/ Psoriasis/ Dry skin/ Sensitive skin/ Other

Muscular/skeletal problems: Back / Aches & pains / Stiff joints / Headaches / Other

Problems with circulation:

Varicose veins/ Oedema/ Chillblains/ Heart problems/ Excessively cold or hot/Sweating / Blood Pressure / Cellulite / Other

Respiratory problems:

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Aromalyne Level 3 Diploma in Aromatherapy (VTCT)

Asthma/ Breathing difficulties/ Bronchitis/ Throat infections/ Sinusitis/ Colds/ Flu/Other

Digestive problems:

Constipation/ Indigestion/ Colitis/ Candida/ Heartburn/ Acidity/ Flatulence/ Other

Urinary problems:

Cystitis/ Thrush/ Fluid Retention/ Problems with urination/ Kidney disease/ Other

Nervous/Endocrine/ Stress related problems:

Anxiety/ Depression/ Headaches/ Migraines/ Insomnia/ Nervous tension/ Mood swings/ High or low energy levels/ Other

Female clients

Pre-menstrual tension/ Menopausal problems/ Problems with periods/ Other

Fertility problems (if appropriate)

Is there any other problem that has not been mentioned that you would like help with as part of this treatment?

LIFESTYLE

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Aromalyne Level 3 Diploma in Aromatherapy (VTCT)

Typical daily diet:

Do you eat regular meals?

Do you eat in a hurry?

Do you suffer from any food allergies?

If so, which ones?

Number of glasses of water consumed daily:

Number of cups of tea/coffee per day:

Supplements taken:

Typical weekly alcohol intake:

Do you smoke? Yes/No If so, how many per day?

Type of exercise taken (and how frequently):

Do you have any hobbies? Do you relax regularly, if so how?

Stress levels 1 – 10 (10 is the highest) At home?

At work?

Have you tried aromatherapy or any other complementary therapies before (state when and what the results were)?

Are you currently having any complementary treatment (give details)?

What is your skin type? Dry / Oily / Combination / Sensitive / Dehydrated

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Aromalyne Level 3 Diploma in Aromatherapy (VTCT)

Postural Analysis:

Body Shape: Endomorph / Mesomorph / Ectomorph

Muscle Tone: Good / Poor

Would you say you are the correct weight for your height / overweight / underweight?

Do you have cellulite / fluid retention / oedema?

Extra notes:

CLIENT DECLARATION

I declare that the information I have given is correct and as far as I am aware I can undertake treatment with this establishment without any adverse effects. I have been fully informed about contra-indications and I am therefore willing to proceed with the treatment.

Client’s Signature: Date:

Therapist’s Signature:

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