Aromatherapy Client Consultation Form

A consultation form that gathers a client's personal details, health history, and preferences before an aromatherapy session, divided into sections for easier completion.

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In the Claude connectors directory

Page 1

Client Name

First Name

Last Name

Age

Gender

Male Female Other

Date of Birth

Telephone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Civil Status

Single Married Divorced Widowed

Employment

Height (cm)

Weight (kg)

Select an appointment

Date

Time

Reason for visit

Page 2

Is it your menstrual period?

Yes No

Are you pregnant?

Yes No

Are you breastfeeding?

Yes No

Have you undergone any surgical procedure? If yes, please explain below

Do you have any allergies? If yes, please list them below

Are you currently taking any medications? If yes, please list them below and explain their purpose

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Do you exercise on a daily or regular basis?

Yes No

Are you currently following a diet plan?

Yes No

Do you have any physical injury?

Yes No

Do you feel any muscle and joint pain?

Yes No

Type of Lifestyle

Active Sedentary Moderately Active

Do you have any of the following contraindications? (Select all that apply)

Epilepsy Deep Vein Thrombosis High Blood Pressure Skin Conditions

Are you currently undergoing physical therapy, chiropractic adjustment, or acupuncture?

Do you have preferred oils and essences?

How often is your treatment plan?

Weekly Biweekly Monthly

Page 3

Client Acknowledgment

Client Signature

Sign here

Date Signed

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