Aroma Therapy client record

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Name:
Address:
Telephone Number:
Occupation:
Primary care doctor:
Date of Birth:

Gender:

Marital Status:

Any Medical History:
Medications being taken:

Are you pregnant or trying to be pregnant?

Any history of intern problems:

Any Allergies:

Main Reasons for Wanting Aromatherapy?

Have you use Aromatherapy Before?

How did you become aware of and choose to explore Aromatherapy?

Please provide a brief description of your general health:

Emotional, Mental, Physical and Spiritual