Blend Discovery Form

Contact Details

First Name

Last Name

Address

Telephone

Email Address

Age

Gender Identity

General Health and Lifestyle

Do you have Children?

Are you Pregnant?

If you are pregnant, how many months?

Do you exercise regularly?

If you exercise, how many times per week?

Do you have any allergies/dietary intolerances/sensitivities?

If you have any of the cases mentioned above, please specify

Do you drink alcohol?

If you drink alcohol, how many units per week?

Do you smoke?

If no, have you ever smoked? When did you stop?

How many hours do you sleep?

Rate your level of stress (10 = overwhelming and 1 = mild stress)

Medical History

Any family history of illness?

If there is a history of illness, please specify

Do you have any major health conditions?

If any major health conditions, please specify

Please check any conditions which may apply to you

Circulatory

High Blood Pressure Low Blood Pressure Varicose veins Sluggish Circulation

Renal

Cystitis Bladder or Kidney infections

Men: Hernia or any other problems?

Lymphatic

Fluid retention Cellulite Slow circulation

Do you use bleaching products?

Precautions: Is there anything else I should be aware of today with regards your health?

Treatment Plan
Emotional and Mental Wellbeing

If the emotion you currently feel isn't listed in the checkbox above, kindly specify here:

What areas would you like to improve?

What is your preferred Aroma type?

Are there any Carrier Oils you do not like or may be allergic to?

Are there any Essentials Oils you do not like or may be allergic to?

Confidentiality: Your responses to the questionnaires will be kept confidential at all times.
Informed Consent

I understand that this consultation is designed to gather information so that the practitioner can design and create aromatic products based upon my individual needs and for the express purpose of supporting health and well-being through lifestyle changes, health habits, and healthy mental well-being.
I understand that my aromatherapy practitioner does not diagnose, prevent, or treat any illness, disease, or any other physical or mental condition.
I understand that I am consulting this practitioner for educational purposes only, of my own free will.
I understand that this treatment is not a substitute for medical treatments, and it is recommended that I see a qualified professional for any physical or mental condition that I may have.
I understand that any evaluation cannot determine a specific disease condition I may have, and that it does not replace the diagnostic services offered by licensed physicians.
I understand that there is no advice or suggestion that I cease medical care I am undertaking.
I understand that the decisions I make regarding my health care are my sole responsibility.
I understand that any instruction, advice, counsel, suggestions, recommendations, services, or products are provided solely for the purpose of supporting the natural function of the body systems, and to improve general health and well-being.
I have read the above information and I hereby give my permission for Nukubi Aroma Therapy to design an aromatic program for me based upon my unique needs and goals.

I confirm that the information given is true to the best of my knowledge and I undertake to inform the therapist of any changes as they may occur.

I confirm that I have read the terms and conditions of this agreement and give my consent.

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