Your Name (required)

D.O.B

Occupation

Telephone number

Your Email (required)

Full Address (including postcode)

Name and address of doctor

Medical History

Please comment on current/recent medication or visits to your doctor.

Do you have diabetes, heart problems, high or low blood pressure or epilepsy? Has your doctor cleared you to undertake massage therapy?

Do you have any physical problems or injuries? Do you have any areas of discomfort, swelling, bruises, inflammation, varicose veins or arthritis?

Have you had any surgery, wounds or broken bones in the last 2 years?

Do you:
 have any allergies (e.g nuts) smoke wear contact lenses

Please comment on lifestyle and sources of stress

Please comment on exercise patterns and fitness level.

Please comment on diet and any use of supplements.

Fluid intake (daily)
Water: Tea: Coffee:
Alcohol: Herbal teas:

Female Clients:
Menstrual Cycle: Date of last period:

By ticking this box I accept that:
I understand the treatment given to me by Carole Ramsdale is for the purpose of helping my problem

I understand that the Essential Oils Consultant does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor is massage part of the treatment.

I understand that Essential Oils are not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.

I have stated all my known physical conditions and medications, and I will keep the Essential Oil Consultant updated on any changes.