Aroma Pharmica :: Nature Inspired Skincare :: Aromatherapy Consultation

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Fill out the Form for an Aromatherapy Consultation

The following questions must be answered to provide a formulation

Name *
E-mail Address: *
Age *
Height *
Weight *
Body Type *
Describe the condition you are interested in attempting to heal with Aromatherapy: *
How long has the condition persisted? *
Has it been recurring? *	Yes No
Is it now or has it been treated by a physician? *	Yes No
Are prescription or homeopathy medications being taken? *	Yes No
Is the formula user: Male or Female? *
If female, are you pregnant?	Yes No
Are you nursing?	Yes No
Are you going through menopause?	Yes No
Does the user have any allergies(especially to plants)? *	Yes No
If so, please list with a comma seperating each allergy
Are there scents the user dislikes? *
What plant scents does the user particularly like? *
Heart Trouble *	Yes No
High or Low Blood Pressure *	Yes No
Diabetes *	Yes No
Arthritis, Bursitis, Rheumatism *	Yes No
Breast or Ovarian Cysts *	Yes No
Cancer *	Yes No
Migraines or Headaches *	Yes No
Seizure disorders *	Yes No
Respiratory problems or disorders *	Yes No
Dizziness or fainting spells *	Yes No
Neurological disorders *	Yes No
Skin disorders *	Yes No
Are there any other medical conditions you have that are not listed above? If so, please list here *


* Required