Aromatherapy for Asthma Intake Form
We'll give you a call as soon as we receive your form and payment! Please enter your information below.
* Full Name:

* Telephone:

* Email Address:

* Is the person with asthma yourself, or your child?

* When were you (or your child) first diagnosed with asthma?

* What is your age (or your child's age) now?

* Please choose the severity of your (or your child's) asthma.

* Please list your medications and their doses:

* Please describe any other health issues (such as insomnia, diabetes, cancer, etc...):

* Please describe your history of antibiotic use:

* Any surgeries? Please explain:

* Are you pregnant or breastfeeding?

* Please list and describe any allergies you might have:

* Have you ever used aromatherapy for health or emotional reasons before?

* Please choose your level of aromatherapy knowledge:

Please leave any comments here you feel will assist us during your Aromatherapy Consultations.

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