Overview
You can work on this assignment in a casual setting at the Ship’s Galley– go down to Deck 3 using the aft stairwell. The Galley is straight ahead, past the Healing Bay and Aphrodite’s Beauty Salon.
After reviewing the interview template, please keep a copy on your computer to have it handy. Please be sure to modify it to suit your needs exactly.
Download your Practical Potion Journal for exercises that include interviewing people.
The Aromatic Intake Form Template
An intake template is a great way to keep relevant and personal information on your clients. It provides contact information and crucial medical information that may impact how you create blends, such as allergies, skin sensitivities, epilepsy, pregnancy, and asthma.
Create a form to collect data that is important to the type of treatments you do. Modify it to ensure it is helpful for your needs.
Client Background Information |
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| Name | |
| Phone Number | |
| Emergency Number | |
| Date of Birth | |
Medical History |
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| Please indicate if you are/you have: | |
| Pregnant | |
| Epileptic – If yes, are you taking medication? | |
| Asthmatic – Please indicate the severity & circumstances. | |
| Allergies or sensitivities – (especially skin and respiratory) | |
| Psoriasis | |
| Other skin disorders or infections. | |
| HIV or Aids. | |
| Cancer (or family history of hormone-sensitive cancers) breast, uterine, ovarian, prostate. | |
| Endocrine: Thyroid, parathyroid, adrenal, pituitary, pancreas, thymus. | |
| Cardio & Heart health- blood pressure, cholesterol, strokes, irregular rhythms etc. | |
| Bowel, stomach, gallbladder, digestive system. | |
| Are or have you ever been under psychiatric care? | |
| Are you currently on any drugs for depression or anxiety? | |
| Any other relevant medical history. | |
Lifestyle |
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| Family composition- | |
| Occupation- | |
| Food patterns. How often do you eat each day? | |
| What type of foods do you eat, and do you eat in a calm environment? | |
| Sleep Cycle- | |
Stress Level |
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| Do you have supportive relationships in your life? | |
| In what area of your life are you most satisfied? | |
| What area of your life is currently being reviewed? | |
Reason for Appointment:
I___________________________________________________________ understand __________________________ is an aromatherapy student, not a medical doctor. I know she may make suggestions but is not diagnosing. I also understand that I am not obligated to implement her recommendations.
I also understand essential oils are potent plant substances. They must not be used internally. Never leave the oil in places accessible to small children or pets. Please don’t apply it to your skin undiluted. Use with extreme caution in cases of epilepsy, asthma, pregnancy, and breastfeeding. Except where your therapist indicates, essential oils are not recommended for babies, infants, or pets. To test for allergic reactions, apply a small amount of undiluted oil to the underside of your arm.
Signature:____________________________________________________
Date:_________________________________________________________
A copy of this template and your homework for this section is in your Practical Potions Journal, located at the bottom of this page. Scroll down and find downloads.
Try interviewing three people. Revise and rewrite the template to suit you. Keep doing this until you get a suitable document. Post your version in the forum if you like so that we can look at it and you can discuss it with other students and practitioners. Please tell us what you think is important in a question. How do you encourage clients to give you honest answers? Where will you keep the filing system you develop for clients? How will you keep their data private and secure?