Opal Cintron Heese

Certified Clinical Aromatherapist

Name:__________________________________ Today's Date:__________

This form and information contained within, is private and confidential. Clinical Aromatherapy is the application of
genuine essential oils for supporting the physical, mental, and spiritual health of the individual. It is not meant as a cure, but
to stimulate and support the body's own natural healing abilities, and encompasses the whole person, body-mind-spirit. It can
be a good compliment to other forms of medicine and health-care.
I understand that it is not to replace treatments by my medical practitioner. As a Certified Clinical Aromatherapist Opal is not
a medical professional and her educated recommendations are meant as education and support, to tonify and strengthen
the bodies natural systems.
I acknowledge that I have read and understand the above information. I will answer the following questions with accurate,
correct and complete information to the best of my ability. This information will allow Opal, to make this experience uniquely
tailored to my personal needs.
Please initial here that you have read the above: ______________________
Address:
___________________________________________Email:______________________________
Phone: ____________________________Cell:_________________________
How do your prefer to be contacted? Email? __Phone:__Cell:__Text ok?:__Email:__
What do you expect to accomplish with Aromatherapy?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Have you used Essential Oils before? How have you used Aromatherapy?

SAFETY WITH ESSENTIAL OILS Q&A: Children?______If so how many?___Ages?_____

Pets and what kind?____________________________________________
How is your overall health? (mark one with an X)
Over all good_______ See doctor frequently for infections_____Have a chronic condition______ Not sure
how to answer______
Any explanation you would like to give regarding quality of health?

Current treatments and do you feel they are affective?

For Women Only: Pregnant women can not use essential oils before 3 rd trimester.
Age:_______Are you trying to conceive? _________Are you pregnant? _____________
Please list any PMS or cycle or reproductive issues IF CONCERN.
_______________________________________________________________________________
_______________________________________________________________________________
For Men Only:
Age:_______Thinning- Hair Loss?______Low libido? _______Skin issues?___________
ED?______________Any other concerns you would like addressed?

THANK YOU FOR YOUR TIME ON THIS. pg1

www.opalsapothecarium.weebly.com
ocintronheese@gmail.com
910*302*6725
Opal Cintron Heese
Certified Clinical Aromatherapist

Please circle any that apply below (currently or in your past):

Some are things which could cause interaction with Essential oils..this is why such detail.

Cancer Epilepsy
Heart Disease Arthritis
Dermatitis Diabetes
Psoriasis High blood pressure
Allergies Low Blood pressure
Asthma Blood clots
Eczema Varicose Veins
Migraines Paralysis
Muscle Disorder :_________________________
TMJ disorder Other: ________________________________
Depression/Anxiety

Mood/ Spirit (nervous system related) :

Depression Constipation/loose bowels (circle which one)
Anxiety/ Nervousness (which one?) Faintness/dizziness
Lack of motivation Cold hands/feet
Indigestion
Fatigue/ Insomnia (circle which one) Vomiting
Pains in chest area or heart Soreness in muscles

Mental confusion or foggy thinking Tightness in body. Where?___________________

Memory problems/ cognitive problems (which one?) Feeling as though spiritually there is something
missing. A lack of connection.
Comments:

Aromatherapy Products: Please circle ones you might enjoy, and put and X through ones
you wouldn't.
Room Spray Bath Salts Bath Oil
Gel (pain/ hand sanitize..) Inhalant Meditation blend
Massage oil Face Spray/mist Scent or roll-on
Infuser/humidifier blend Scented necklace Scented cotton pads
Scented bracelet Liniment (alcohol based)

THANK YOU FOR YOUR TIME ON THIS. pg2

www.opalsapothecarium.weebly.com
ocintronheese@gmail.com
910*302*6725
Opal Cintron Heese
Certified Clinical Aromatherapist

AROMA-PROFILE...
What AROMAS do you enjoy? List any that come to mind...
______________________________________________________________________________________________________________
Circle some smells you like and leave ones you don't like untouched below:

Vicks Cedarwood Sandalwood Baby oil Clove

Cinnamon

Rosemary
Lime Orange Lemon
Vanilla
Fresh Laundry

Dirt Moss
Pine
Rose Lavender
Jasmine

What smells bother you or don't you like?

______________________________________________________________________________________________

SKIN TYPE:
Please circle the appropriate choice for your skin type:
Normal---Sensitive--- Oily---Combination
Please list any skin conditions that are not mentioned above: (ex...psoriasis, eczema, acne,
warts....)__________________________________________________________________________________

A note about skin care:

Clinical Aromatherapy products excel in healing skin, keeping skin's youthful appearance and
helping to maintain a healthy and vibrant complexion.
If you are interested in working toward better skin with me. Please list below any skin
maintenance concerns you may have.

THANK YOU FOR YOUR TIME ON THIS. pg3

www.opalsapothecarium.weebly.com
ocintronheese@gmail.com
910*302*6725