Appointments 1 — botanical blends and balance

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DOB

Occupation

Reason For Appointment

What is your primary concern? What causes it?

List allergies if any

Are you taking any medications?

Please list type and date of all surgeries:

Please describe your current exercise routine:

How many hours of sleep do you get per night on average?

Are there particular scents or aromas that disturb you?

Are there particular scents or aromas that you especially enjoy?

Do you have other symptoms or concerns that have not been covered?

Please read and sign:

I have stated all my known conditions and have answered all questions honestly. I take it upon myself to keep the practitioner updated on my health. I understand that the consultant does not diagnose, prevent or treat illness, disease or any other physical or mental conditions. I understand that this treatment is not a substitute for medical treatments and/or diagnosis, and it is recommended that I see a qualified professional for any physical or mental condition that I may have. I understand this treatment is not a substitute for medical care. The Practitioner has provided and explained the safety issues surrounding my treatment plan. I have had the opportunity to ask any questions. I understand the following: I am not being advised to take any essential oil products internally I must keep all essential oil products out of the reach of children Essential oils could be poisonous if swallowed Essential oils must be stored in a cool, dark place Essential oils may irritate the skin if not stored or used properly Essential Oils must not be used with animals Essential Oils must not be used on the skin of babies or children under 1 years old Essential Oils must be used with extreme caution for children under 5 years old. I hold Michelle Montgomery, CA harmless for any injuries or negative effects I may experience as a result of using the products I receive during this consultation, or from consultant in the course of my treatment plan.

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