Aromatherapy

Gentle Touch Consultation Form

Your Full Name: Date: Gentle Touch Aromatherapist: Age Group: Lifestyle: Last visit to the doctor: No. of children (if applicable): Date of last period(if applicable):

Contraindications Requiring Medical Permission

Contraindications that completely restrict treatment

Contraindications that partially restrict treatment

Personal Health Information

Muscular/Skeletal Problems: Digestive Problems: Circulation Problems: Gynaecological / Urinary System: Nervous / Endocrine System: Lymphatic / Immune System: Regular antibiotic/medication taken?
Yes No If yes, which ones? Herbal remedies taken?
Yes No If yes, which ones? Ability to relax:
Good Moderate Poor Sleep patterns:
Good Poor Average Number of hours sleep: Do you see natural daylight in your workplace?
Yes No Do you work at a computer?
Yes No If yes, how many hours? Do you eat regular meals?
Yes No Do you eat in a hurry?
Yes No Do you take any food / vitamin supplements?
Yes No If yes, which ones?

Daily Diet

How many portions

Fresh fruit: Fresh vegetables: Protein (source): Dairy produce: Sweet things: Added salt: Added sugar:

Drinks per Day

Tea: Coffee: Fruit juice: Water: Soft drinks: Others:

Lifestyle

Do you suffer from food allergies?
Yes No Types of allergy: Binge eating?
Yes No Overeating?
Yes No Do you smoke?
Yes No How many per day? Do you drink alcohol?
Yes No How many units per day?

Exercise

Types of Exercise:

Skin

What is your skin type? Have you suffered from:

Stress

How high are your stress levels: Scale of 1–10 (where 1 is the lowest)

Stress level (Home): Stress level (Work): Reason for treatment:

Consent

I confirm that the information I have given is correct and that I will advise of any changes. I understand students are in training and agree they may use this information as part of case studies or course work.

I have received GP verbal consent for this contraindication. I have been informed and understand the implications of this contraindication and wish to proceed with this course of treatment. Client Signature: Date: