Please read carefully and fill out in detail all sections relevant to the best of your knowledge. It is important to list all medications and supplements being taken at this time.

Name:

Address:

Phone:

Mobile:

Your Email:

Date of birth:

Medical History

Blood pressure:
 High Low Normal

Heart Condition:
 Yes No

If Yes, Please give details of Heart Condition:

Digestive:

Immune:

Muscular:

Arthritis:

Injuries:

Nervous:
 Insomnia Depression Tension Stress Anxiety

Psychological / Emotional:

Are you Pregnant?:
 Yes No

If Yes, What Stage?:

Menstrual Cycle:
 Heavy Light Painful

Menopausal:
 Yes No

If Yes, Describe your symptoms:

Smoker:
 Yes No

Asthma:
 Yes No

Allergies:
 Yes No

Smell Preference:
 Floral Herbs Woody Citrus Spicy

Do you have a favourite perfume?

What are your Astrology Sun, Moon and Rising Signs?

Would you like to be informed of upcoming workshops?
 Yes No

N.B. Aromatique Essentials makes no claim to cure any condition. Aromatherapy is a support therapy aiming to promote balance between body, mind and soul.

Thank You for choosing Aromatique Essentials.
Your feedback and comments are encouraged and valued.
We look forward to hearing from you.