Honey Sweetie

Medical Questionnaire for Personally Formulated Ointment

 

    Name (required):

    Email (required):

    Address:

    City:

    State:

    Zip:

    Cell Phone:

    Medication:

    Physician:

    Birth Date:

    Referred By:

    Primary Reason for Ointment or Roll-on:

    Please answer the following questions by checking the appropriate answer. Please explain any Yes answers below.

    01. Do you have any spinal problems?
    02. Do you take any prescribed medications?
    03. Do you have chronic back pain?
    04. Do you have frequent headaches?
    05. Are you constantly tired?
    06. Do you have any heart problems?
    07. Do you have high blood pressure?
    08. Are you on any blood thinning medications?
    09. Have you ever had cancer?
    10. Do you have arthritis?
    11. Have you ever suffered any acute injury?
    12. Do you have pain that radiates down your arms or legs?
    13. Do you suffer from tension?

    Please explain any Yes anwsers:

    Do you have any other medical condition which I should be aware?
    If so please specify:

    I, , understand that the science of aromatherapy and the use of essential oils is an alternate modality in pursuit of relief from pain, stiffness, or other types of discomfort. I further understand that products made with essential oils must be a good match with my personal body chemistry to work as expected.

    I understand that a Certified Aroma therapist does not diagnose illness or disease or any other physical disorder. While trained in skin anatomy and function, an Aromatherapist is not a licensed Dermatologist.

    I will use any essential oil preparation exactly as directed and will not apply more than advised. In addition, I will stop using the product immediately and notify the Aromatherapist if a skin reaction of any type occurs.

    Because essential oil formulations are nature’s chemicals they can affect the outcome of prescription medication, I have provided all information regarding any medication I am currently taking. I agree to keep the Aromatherapist updated to any changes in my medications or my medical history.

    Signature/Name: Date:

     

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